{ "hospital_name": "Oklahoma Heart Hospital, LLC", "hospital_address": [ "4050 West Memorial Road Oklahoma City, OK 73120", "5224 East I240 Service Road Oklahoma City, OK 73135", "5401 North Portland, Suite 380 Oklahoma City, OK 73112", "8121 National Avenue Suite 200 Midwest City, OK 73110", "8121 National Avenue Suite 300 Midwest City, OK 73110", "5224 E. I-240 Service Road Suite 201 Oklahoma City, OK 73135", "5224 E. I-240 Service Road Suite 301 Oklahoma City, OK 73135", "5224 E. I-240 Service Road Suite 303 Oklahoma City, OK 73135", "6801 Northwest 39th Street Suite C Bethany, OK 73008", "4200 West Memorial Suite 410 Oklahoma City, OK 73120", "4200 West Memorial Suite 807 Oklahoma City, OK 73120", "520 South Mustang Road Suite S Yukon, OK 73099", "2017 W. I-35 Frontage Road Suite 240 Edmond, OK 73013", "412 S. Air Depot Blvd Suite B Midwest City, OK 73135", "8121 National Avenue, Suite 150 Midwest City, OK 73110", "8121 National Avenue, Suite 209 Midwest City, OK 73110", "8121 National Avenue Suite 104 Midwest City, OK 73110" ], "last_updated_on": "2026-03-27", "attestation": { "attestation": "To the best of its knowledge and belief, this hospital has included all applicable standard charge information in accordance with the requirements of 45 CFR 180.50, and the information encoded is true, accurate, and complete as of the date in the file. This hospital has included all payer-specific negotiated charges in dollars that can be expressed as a dollar amount. For payer-specific negotiated charges that cannot be expressed as a dollar amount in the machine-readable file or not knowable in advance, the hospital attests that the payer-specific negotiated charge is based on a contractual algorithm, percentage or formula that precludes the provision of a dollar amount and has provided all necessary information available to the hospital for the public to be able to derive the dollar amount, including, but not limited to, the specific fee schedule or components referenced in such percentage, algorithm or formula.", "confirm_attestation": true, "attester_name": "Andrew Wirth" }, "license_information": { "state": "OK", "license_number": "OK 2354" }, "version": "3.0.0", "location_name": [ "Oklahoma Heart Hospital, LLC", "Oklahoma Heart Hospital, LLC", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Clinic", "Oklahoma Heart Hospital Outpatient Center", "Oklahoma Heart Hospital Outpatient Center", "Oklahoma Heart Hospital Outpatient Cath Lab" ], "type_2_npi": [ "1083617005" ], "standard_charge_information": [ { "description": "HC Percutaneous Intracoronary Drug-Delivery Balloon (Agent Dcb)", "code_information": [ { "code": "CASE-0913T", "type": "LOCAL" }, { "code": "0913T", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 20687.69, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 15543.99, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 7592.76, "10th_percentile": 7592.76, "90th_percentile": 7592.76 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 40.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 27757.13, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 22205.7, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 50964.65, "standard_charge_algorithm": "Case rate ($50,964.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 58610.21, "standard_charge_algorithm": "Case rate ($58,610.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 35107.84, "standard_charge_algorithm": "Case rate ($35,107.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 41.23, "standard_charge_algorithm": "Fee schedule rate ($41.23).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 41.23, "standard_charge_algorithm": "Fee schedule rate ($41.23).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 5423.4, "10th_percentile": 5423.4, "90th_percentile": 5423.4 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11435.94, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 41.23, "maximum": 58610.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Drainage of Hematoma,Fluid", "code_information": [ { "code": "CASE-10140", "type": "LOCAL" }, { "code": "10140", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6549.58, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1687.37, "standard_charge_algorithm": "APC Rate ($1,687.37). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1687.37, "standard_charge_algorithm": "APC Rate ($1,687.37). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2223.84, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 2225.87, "standard_charge_algorithm": "Case rate ($2,225.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3971.14, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3176.91, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 1576.36, "standard_charge_algorithm": "Case rate ($1,576.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 1812.84, "standard_charge_algorithm": "Case rate ($1,812.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 1085.9, "standard_charge_algorithm": "Case rate ($1,085.90). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 855.78, "standard_charge_algorithm": "Case rate ($855.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 855.78, "standard_charge_algorithm": "Case rate ($855.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 855.78, "standard_charge_algorithm": "Case rate ($855.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1487.27, "standard_charge_algorithm": "Case rate ($1,487.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "1 through 10", "median_amount": 1421.6, "10th_percentile": 1421.6, "90th_percentile": 1421.6 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1487.27, "standard_charge_algorithm": "Case rate ($1,487.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 1541.2, "10th_percentile": 1541.2, "90th_percentile": 1541.2 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1636.11, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 855.78, "maximum": 3971.14, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Trim Benign Hyperkeratotic Skin Lesion,2-4", "code_information": [ { "code": "CASE-11056", "type": "LOCAL" }, { "code": "11056", "type": "CPT" }, { "code": "510", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 171.74, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 204.98, "standard_charge_algorithm": "APC Rate ($204.98). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 204.98, "standard_charge_algorithm": "APC Rate ($204.98). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 192.96, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 270.15, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 482.41, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 192.96, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 385.93, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 1399.99, "standard_charge_algorithm": "Case rate ($1,399.99). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 192.96, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 1610.01, "standard_charge_algorithm": "Case rate ($1,610.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 964.4, "standard_charge_algorithm": "Case rate ($964.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 760.03, "standard_charge_algorithm": "Case rate ($760.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 760.03, "standard_charge_algorithm": "Case rate ($760.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 760.03, "standard_charge_algorithm": "Case rate ($760.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 192.96, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 67.4, "standard_charge_algorithm": "Fee schedule rate ($67.40).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 67.4, "standard_charge_algorithm": "Fee schedule rate ($67.40).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 192.96, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 192.96, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 192.96, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 192.96, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 189.01, "10th_percentile": 189.01, "90th_percentile": 189.01 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 192.96, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 198.75, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 192.96, "standard_charge_algorithm": "APC Price ($192.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 67.4, "maximum": 1610.01, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Excision Malignant Lesion Trunk/Arm/Leg > 4.0 Cm", "code_information": [ { "code": "CASE-11606", "type": "LOCAL" }, { "code": "11606", "type": "CPT" }, { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7862.46, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1532.0, "standard_charge_algorithm": "Case rate ($1,532). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1687.37, "standard_charge_algorithm": "APC Rate ($1,687.37). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1687.37, "standard_charge_algorithm": "APC Rate ($1,687.37). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2223.84, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3971.14, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3176.91, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 10139.04, "standard_charge_algorithm": "Case rate ($10,139.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 11660.07, "standard_charge_algorithm": "Case rate ($11,660.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6984.45, "standard_charge_algorithm": "Case rate ($6,984.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 5504.35, "standard_charge_algorithm": "Case rate ($5,504.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 5504.35, "standard_charge_algorithm": "Case rate ($5,504.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 5504.35, "standard_charge_algorithm": "Case rate ($5,504.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1487.27, "standard_charge_algorithm": "Case rate ($1,487.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1487.27, "standard_charge_algorithm": "Case rate ($1,487.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1636.11, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1487.27, "maximum": 11660.07, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Debridement of Nail(S) 1-5", "code_information": [ { "code": "CASE-11720", "type": "LOCAL" }, { "code": "11720", "type": "CPT" }, { "code": "510", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 69.01, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 79.43, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 141.84, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 113.47, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 489.65, "standard_charge_algorithm": "Case rate ($489.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 563.11, "standard_charge_algorithm": "Case rate ($563.11). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 337.31, "standard_charge_algorithm": "Case rate ($337.31). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 265.83, "standard_charge_algorithm": "Case rate ($265.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 265.83, "standard_charge_algorithm": "Case rate ($265.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 265.83, "standard_charge_algorithm": "Case rate ($265.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 27.7, "standard_charge_algorithm": "Fee schedule rate ($27.70).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 27.7, "standard_charge_algorithm": "Fee schedule rate ($27.70).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 56.5, "10th_percentile": 53.56, "90th_percentile": 56.5 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 58.44, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 27.7, "maximum": 1143.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Debridement of Nails 6 or More", "code_information": [ { "code": "CASE-11721", "type": "LOCAL" }, { "code": "11721", "type": "CPT" }, { "code": "510", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 76.75, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 79.43, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 141.84, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 113.47, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 489.65, "standard_charge_algorithm": "Case rate ($489.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 563.11, "standard_charge_algorithm": "Case rate ($563.11). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 337.31, "standard_charge_algorithm": "Case rate ($337.31). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 265.83, "standard_charge_algorithm": "Case rate ($265.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 265.83, "standard_charge_algorithm": "Case rate ($265.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 265.83, "standard_charge_algorithm": "Case rate ($265.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 38.12, "standard_charge_algorithm": "Fee schedule rate ($38.12).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 38.12, "standard_charge_algorithm": "Fee schedule rate ($38.12).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 56.5, "10th_percentile": 56.5, "90th_percentile": 56.5 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 58.44, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 38.12, "maximum": 1143.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Layr Clos Wnd Trunk,Arm,Leg 2.6-7.5 Cm", "code_information": [ { "code": "CASE-12032", "type": "LOCAL" }, { "code": "12032", "type": "CPT" }, { "code": "450", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7862.46, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1687.37, "standard_charge_algorithm": "APC Rate ($1,687.37). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1687.37, "standard_charge_algorithm": "APC Rate ($1,687.37). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2223.84, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3971.14, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3176.91, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 10139.04, "standard_charge_algorithm": "Case rate ($10,139.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 11660.07, "standard_charge_algorithm": "Case rate ($11,660.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6984.45, "standard_charge_algorithm": "Case rate ($6,984.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 5504.35, "standard_charge_algorithm": "Case rate ($5,504.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 5504.35, "standard_charge_algorithm": "Case rate ($5,504.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 5504.35, "standard_charge_algorithm": "Case rate ($5,504.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1487.27, "standard_charge_algorithm": "Case rate ($1,487.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1487.27, "standard_charge_algorithm": "Case rate ($1,487.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1636.11, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1143.0, "maximum": 11660.07, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Inject Tendon Sheath/Ligament", "code_information": [ { "code": "CASE-20550", "type": "LOCAL" }, { "code": "20550", "type": "CPT" }, { "code": "510", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 251.49, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 313.6, "standard_charge_algorithm": "APC Rate ($313.60). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 313.6, "standard_charge_algorithm": "APC Rate ($313.60). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 413.3, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 738.04, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 590.43, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 1979.13, "standard_charge_algorithm": "Case rate ($1,979.13). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 2276.03, "standard_charge_algorithm": "Case rate ($2,276.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 1363.35, "standard_charge_algorithm": "Case rate ($1,363.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 1074.44, "standard_charge_algorithm": "Case rate ($1,074.44). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 1074.44, "standard_charge_algorithm": "Case rate ($1,074.44). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 1074.44, "standard_charge_algorithm": "Case rate ($1,074.44). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 276.41, "standard_charge_algorithm": "Fee schedule rate ($276.41).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 276.41, "standard_charge_algorithm": "Fee schedule rate ($276.41).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 304.07, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 276.41, "maximum": 2276.03, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Removal Implant Superficial Separate Procedure", "code_information": [ { "code": "CASE-20670", "type": "LOCAL" }, { "code": "20670", "type": "CPT" }, { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5659.77, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1687.37, "standard_charge_algorithm": "APC Rate ($1,687.37). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1687.37, "standard_charge_algorithm": "APC Rate ($1,687.37). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 3806.7, "10th_percentile": 3806.7, "90th_percentile": 3806.7 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2223.84, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3971.14, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3176.91, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 10139.04, "standard_charge_algorithm": "Case rate ($10,139.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 11660.07, "standard_charge_algorithm": "Case rate ($11,660.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6984.45, "standard_charge_algorithm": "Case rate ($6,984.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 5504.35, "standard_charge_algorithm": "Case rate ($5,504.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 5504.35, "standard_charge_algorithm": "Case rate ($5,504.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 5504.35, "standard_charge_algorithm": "Case rate ($5,504.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1487.27, "standard_charge_algorithm": "Case rate ($1,487.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1487.27, "standard_charge_algorithm": "Case rate ($1,487.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 1541.2, "10th_percentile": 1541.2, "90th_percentile": 1541.2 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1636.11, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1143.0, "maximum": 11660.07, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Close Median Sternotomy Sep W/WO Debridement Spx", "code_information": [ { "code": "CASE-21750", "type": "LOCAL" }, { "code": "21750", "type": "CPT" }, { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 18815.27, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 2167.0, "standard_charge_algorithm": "Case rate ($2,167). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 7413.38, "standard_charge_algorithm": "APC Rate ($7,413.38). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 7413.38, "standard_charge_algorithm": "APC Rate ($7,413.38). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6978.81, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 9770.33, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 40.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17447.02, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6978.81, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13957.62, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 23713.84, "standard_charge_algorithm": "Case rate ($23,713.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 27271.31, "standard_charge_algorithm": "Case rate ($27,271.31). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 16335.67, "standard_charge_algorithm": "Case rate ($16,335.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 12873.91, "standard_charge_algorithm": "Case rate ($12,873.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 12873.91, "standard_charge_algorithm": "Case rate ($12,873.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 12873.91, "standard_charge_algorithm": "Case rate ($12,873.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6978.81, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 579.09, "standard_charge_algorithm": "Fee schedule rate ($579.09).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 579.09, "standard_charge_algorithm": "Fee schedule rate ($579.09).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6978.81, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6978.81, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6978.81, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6978.81, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6978.81, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7188.17, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6978.81, "standard_charge_algorithm": "APC Price ($6,978.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 579.09, "maximum": 27271.31, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Brnchsc Brushing/Protected Brushings", "code_information": [ { "code": "CASE-31623", "type": "LOCAL" }, { "code": "31623", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2281.22, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1532.0, "standard_charge_algorithm": "Case rate ($1,532). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3809.1, "standard_charge_algorithm": "APC Rate ($3,809.10). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3809.1, "standard_charge_algorithm": "APC Rate ($3,809.10). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5020.13, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 8964.53, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7171.62, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6904.64, "standard_charge_algorithm": "Case rate ($6,904.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 7940.46, "standard_charge_algorithm": "Case rate ($7,940.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 4756.38, "standard_charge_algorithm": "Case rate ($4,756.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1602.81, "standard_charge_algorithm": "Case rate ($1,602.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1602.81, "standard_charge_algorithm": "Case rate ($1,602.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 1640.35, "10th_percentile": 1640.35, "90th_percentile": 1640.35 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3693.38, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1532.0, "maximum": 8964.53, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Brnchsc W/Brncl Alveolar Lavage", "code_information": [ { "code": "CASE-31624", "type": "LOCAL" }, { "code": "31624", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2250.95, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1532.0, "standard_charge_algorithm": "Case rate ($1,532). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1818.45, "standard_charge_algorithm": "APC Rate ($1,818.45). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1818.45, "standard_charge_algorithm": "APC Rate ($1,818.45). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 4051.6, "10th_percentile": 4051.6, "90th_percentile": 4051.6 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2396.59, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4279.63, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3423.7, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6904.64, "standard_charge_algorithm": "Case rate ($6,904.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 7940.46, "standard_charge_algorithm": "Case rate ($7,940.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 4756.38, "standard_charge_algorithm": "Case rate ($4,756.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1602.81, "standard_charge_algorithm": "Case rate ($1,602.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1602.81, "standard_charge_algorithm": "Case rate ($1,602.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 1640.35, "10th_percentile": 1640.35, "90th_percentile": 1640.35 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 1640.35, "10th_percentile": 1640.35, "90th_percentile": 1640.35 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1763.21, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1532.0, "maximum": 7940.46, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Bronchoscopy Bronchial/Endobrncl Bx 1+ Sites", "code_information": [ { "code": "CASE-31625", "type": "LOCAL" }, { "code": "31625", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2281.22, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1532.0, "standard_charge_algorithm": "Case rate ($1,532). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3809.1, "standard_charge_algorithm": "APC Rate ($3,809.10). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3809.1, "standard_charge_algorithm": "APC Rate ($3,809.10). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5020.13, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 8964.53, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7171.62, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6904.64, "standard_charge_algorithm": "Case rate ($6,904.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 7940.46, "standard_charge_algorithm": "Case rate ($7,940.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 4756.38, "standard_charge_algorithm": "Case rate ($4,756.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1602.81, "standard_charge_algorithm": "Case rate ($1,602.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1602.81, "standard_charge_algorithm": "Case rate ($1,602.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3693.38, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1532.0, "maximum": 8964.53, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Bronchoscopy W/Transbronchial Lung Bx 1 Lobe", "code_information": [ { "code": "CASE-31628", "type": "LOCAL" }, { "code": "31628", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3027.65, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1532.0, "standard_charge_algorithm": "Case rate ($1,532). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3809.1, "standard_charge_algorithm": "APC Rate ($3,809.10). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3809.1, "standard_charge_algorithm": "APC Rate ($3,809.10). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5020.13, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 8964.53, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7171.62, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6904.64, "standard_charge_algorithm": "Case rate ($6,904.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 7940.46, "standard_charge_algorithm": "Case rate ($7,940.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 4756.38, "standard_charge_algorithm": "Case rate ($4,756.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 3748.43, "standard_charge_algorithm": "Case rate ($3,748.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3357.39, "standard_charge_algorithm": "Case rate ($3,357.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3357.39, "standard_charge_algorithm": "Case rate ($3,357.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3693.38, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1532.0, "maximum": 8964.53, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Insertion Indwelling Tunneled Pleural Catheter", "code_information": [ { "code": "CASE-32550", "type": "LOCAL" }, { "code": "32550", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4507.31, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1532.0, "standard_charge_algorithm": "Case rate ($1,532). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3657.95, "standard_charge_algorithm": "APC Rate ($3,657.95). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3657.95, "standard_charge_algorithm": "APC Rate ($3,657.95). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4820.93, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 8052.84, "standard_charge_algorithm": "Case rate ($8,052.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 8608.8, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6887.04, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 4153.58, "standard_charge_algorithm": "Case rate ($4,153.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 4776.68, "standard_charge_algorithm": "Case rate ($4,776.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 2861.26, "standard_charge_algorithm": "Case rate ($2,861.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3224.17, "standard_charge_algorithm": "Case rate ($3,224.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3224.17, "standard_charge_algorithm": "Case rate ($3,224.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3546.83, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1532.0, "maximum": 8608.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Thoracentesis Needle/Cath Pleura W/Imaging", "code_information": [ { "code": "CASE-32555", "type": "LOCAL" }, { "code": "32555", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 961.49, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 640.89, "standard_charge_algorithm": "APC Rate ($640.89). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 640.89, "standard_charge_algorithm": "APC Rate ($640.89). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 1610.01, "10th_percentile": 1610.01, "90th_percentile": 1610.01 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 844.65, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1508.3, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1206.64, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 4153.58, "standard_charge_algorithm": "Case rate ($4,153.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 4776.68, "standard_charge_algorithm": "Case rate ($4,776.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 2861.26, "standard_charge_algorithm": "Case rate ($2,861.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 254.99, "standard_charge_algorithm": "Fee schedule rate ($254.99).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 254.99, "standard_charge_algorithm": "Fee schedule rate ($254.99).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 588.1, "10th_percentile": 588.1, "90th_percentile": 588.1 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "22", "median_amount": 588.1, "10th_percentile": 441.08, "90th_percentile": 588.1 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 621.42, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 254.99, "maximum": 4776.68, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Pacemaker, Insert Total System W/Sngl Atrial Lead", "code_information": [ { "code": "CASE-33206", "type": "LOCAL" }, { "code": "33206", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 12892.2, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 17763.0, "standard_charge_algorithm": "Case rate ($17,763).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 10678.38, "standard_charge_algorithm": "APC Rate ($10,678.38). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 10678.38, "standard_charge_algorithm": "APC Rate ($10,678.38). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 17573.85, "10th_percentile": 17573.85, "90th_percentile": 17573.85 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 14073.38, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 17573.85, "standard_charge_algorithm": "Case rate ($17,573.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25131.03, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 20104.83, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 49722.16, "standard_charge_algorithm": "Case rate ($49,722.16). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 57181.32, "standard_charge_algorithm": "Case rate ($57,181.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 34251.93, "standard_charge_algorithm": "Case rate ($34,251.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 26993.46, "standard_charge_algorithm": "Case rate ($26,993.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 26993.46, "standard_charge_algorithm": "Case rate ($26,993.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 26993.46, "standard_charge_algorithm": "Case rate ($26,993.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 383.28, "standard_charge_algorithm": "Fee schedule rate ($383.28).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 383.28, "standard_charge_algorithm": "Fee schedule rate ($383.28).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10353.99, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 383.28, "maximum": 57181.32, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Ep Inser Hart Pacer Xvenous Ventr", "code_information": [ { "code": "CASE-33207", "type": "LOCAL" }, { "code": "33207", "type": "CPT" }, { "code": "480", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13912.48, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 17763.0, "standard_charge_algorithm": "Case rate ($17,763).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 10678.38, "standard_charge_algorithm": "APC Rate ($10,678.38). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 10678.38, "standard_charge_algorithm": "APC Rate ($10,678.38). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 14073.38, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 20498.3, "standard_charge_algorithm": "Case rate ($20,498.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25131.03, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 20104.83, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 49722.16, "standard_charge_algorithm": "Case rate ($49,722.16). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 57181.32, "standard_charge_algorithm": "Case rate ($57,181.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 34251.93, "standard_charge_algorithm": "Case rate ($34,251.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 26993.46, "standard_charge_algorithm": "Case rate ($26,993.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 26993.46, "standard_charge_algorithm": "Case rate ($26,993.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 26993.46, "standard_charge_algorithm": "Case rate ($26,993.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 403.94, "standard_charge_algorithm": "Fee schedule rate ($403.94).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 403.94, "standard_charge_algorithm": "Fee schedule rate ($403.94).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10353.99, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 403.94, "maximum": 57181.32, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Ep Inser Hart Pacer Xvenous Atr/Ventr", "code_information": [ { "code": "CASE-33208", "type": "LOCAL" }, { "code": "33208", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 12797.2, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 17763.0, "standard_charge_algorithm": "Case rate ($17,763).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 10678.38, "standard_charge_algorithm": "APC Rate ($10,678.38). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 10678.38, "standard_charge_algorithm": "APC Rate ($10,678.38). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 14073.38, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 21117.24, "standard_charge_algorithm": "Case rate ($21,117.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25131.03, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 20104.83, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 49722.16, "standard_charge_algorithm": "Case rate ($49,722.16). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 57181.32, "standard_charge_algorithm": "Case rate ($57,181.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 34251.93, "standard_charge_algorithm": "Case rate ($34,251.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 26993.46, "standard_charge_algorithm": "Case rate ($26,993.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 26993.46, "standard_charge_algorithm": "Case rate ($26,993.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 26993.46, "standard_charge_algorithm": "Case rate ($26,993.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 9412.07, "standard_charge_algorithm": "Case rate ($9,412.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 9412.07, "standard_charge_algorithm": "Case rate ($9,412.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "34", "median_amount": 9954.83, "10th_percentile": 9349.44, "90th_percentile": 9954.83 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10353.99, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10052.41, "standard_charge_algorithm": "APC Price ($10,052.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 9412.07, "maximum": 57181.32, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Ep Rpsg Prev Implted Pm/Dfb R Atr/R Ventr Electrode", "code_information": [ { "code": "CASE-33215", "type": "LOCAL" }, { "code": "33215", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4029.18, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 25165.0, "standard_charge_algorithm": "Case rate ($25,165).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 5108.43, "standard_charge_algorithm": "Case rate ($5,108.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 13448.29, "standard_charge_algorithm": "Case rate ($13,448.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 15465.76, "standard_charge_algorithm": "Case rate ($15,465.76). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 9264.08, "standard_charge_algorithm": "Case rate ($9,264.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 7300.89, "standard_charge_algorithm": "Case rate ($7,300.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 7300.89, "standard_charge_algorithm": "Case rate ($7,300.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 7300.89, "standard_charge_algorithm": "Case rate ($7,300.89). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "1 through 10", "median_amount": 2802.9, "10th_percentile": 2802.9, "90th_percentile": 2802.9 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 3113.72, "10th_percentile": 3113.72, "90th_percentile": 3113.72 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 2843.33, "maximum": 25165.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Ep Removal Implantable Defib Pulse Generator Only", "code_information": [ { "code": "CASE-33241", "type": "LOCAL" }, { "code": "33241", "type": "CPT" }, { "code": "480", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 44561.23, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 25165.0, "standard_charge_algorithm": "Case rate ($25,165).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 32068.73, "standard_charge_algorithm": "APC Rate ($32,068.73). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 32068.73, "standard_charge_algorithm": "APC Rate ($32,068.73). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 42264.41, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 9215.31, "standard_charge_algorithm": "Case rate ($9,215.31). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 75472.15, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 60377.72, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 3303.74, "standard_charge_algorithm": "Fee schedule rate ($3,303.74).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 128156.22, "standard_charge_algorithm": "Case rate ($128,156.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 147381.81, "standard_charge_algorithm": "Case rate ($147,381.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 88282.52, "standard_charge_algorithm": "Case rate ($88,282.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 69574.21, "standard_charge_algorithm": "Case rate ($69,574.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 69574.21, "standard_charge_algorithm": "Case rate ($69,574.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 69574.21, "standard_charge_algorithm": "Case rate ($69,574.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 28265.83, "standard_charge_algorithm": "Case rate ($28,265.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 28265.83, "standard_charge_algorithm": "Case rate ($28,265.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 31094.53, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 3303.74, "maximum": 147381.81, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Loop Rec Insertion", "code_information": [ { "code": "CASE-33285", "type": "LOCAL" }, { "code": "33285", "type": "CPT" }, { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 11588.81, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 13250.67, "10th_percentile": 13250.67, "90th_percentile": 13250.67 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 5574.9, "10th_percentile": 5574.9, "90th_percentile": 5574.9 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 8454.63, "standard_charge_algorithm": "APC Rate ($8,454.63). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 8454.63, "standard_charge_algorithm": "APC Rate ($8,454.63). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 18598.32, "10th_percentile": 10183.97, "90th_percentile": 19444.18 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7959.02, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 11142.63, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 11021.19, "10th_percentile": 11021.19, "90th_percentile": 11021.19 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 18598.32, "standard_charge_algorithm": "Case rate ($18,598.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 19897.55, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 7959.02, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 7872.28, "10th_percentile": 7872.28, "90th_percentile": 7872.28 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 15918.04, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 19067.93, "standard_charge_algorithm": "Case rate ($19,067.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7959.02, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 21928.44, "standard_charge_algorithm": "Case rate ($21,928.44). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 13135.26, "standard_charge_algorithm": "Case rate ($13,135.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10351.71, "standard_charge_algorithm": "Case rate ($10,351.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 10351.71, "standard_charge_algorithm": "Case rate ($10,351.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 10351.71, "standard_charge_algorithm": "Case rate ($10,351.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 7959.02, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 7872.28, "10th_percentile": 7872.28, "90th_percentile": 7872.28 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7452.03, "standard_charge_algorithm": "Case rate ($7,452.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "1 through 10", "median_amount": 13624.17, "10th_percentile": 7261.39, "90th_percentile": 13624.17 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7452.03, "standard_charge_algorithm": "Case rate ($7,452.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "1 through 10", "median_amount": 7369.88, "10th_percentile": 7369.88, "90th_percentile": 7369.88 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 7959.02, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 8187.17, "10th_percentile": 7736.0, "90th_percentile": 8187.17 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7959.02, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 7959.02, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "15", "median_amount": 7872.28, "10th_percentile": 7872.28, "90th_percentile": 7872.28 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 7959.02, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "30", "median_amount": 7872.28, "10th_percentile": 7438.46, "90th_percentile": 7872.28 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7959.02, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 8197.79, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7959.02, "standard_charge_algorithm": "APC Price ($7,959.02). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1143.0, "maximum": 21928.44, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Removal of Loop Recorder", "code_information": [ { "code": "CASE-33286", "type": "LOCAL" }, { "code": "33286", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 782.05, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 1410.32, "10th_percentile": 1410.32, "90th_percentile": 1410.32 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 723.47, "standard_charge_algorithm": "APC Rate ($723.47). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 723.47, "standard_charge_algorithm": "APC Rate ($723.47). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 1582.05, "10th_percentile": 1223.84, "90th_percentile": 1653.06 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 681.06, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 953.48, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 936.98, "10th_percentile": 936.98, "90th_percentile": 936.98 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 1742.52, "standard_charge_algorithm": "Case rate ($1,742.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1702.65, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 681.06, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1362.12, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 4912.14, "standard_charge_algorithm": "Case rate ($4,912.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 681.06, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 5649.04, "standard_charge_algorithm": "Case rate ($5,649.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 3383.81, "standard_charge_algorithm": "Case rate ($3,383.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2666.73, "standard_charge_algorithm": "Case rate ($2,666.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2666.73, "standard_charge_algorithm": "Case rate ($2,666.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2666.73, "standard_charge_algorithm": "Case rate ($2,666.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 681.06, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 107.5, "standard_charge_algorithm": "Fee schedule rate ($107.50).", "count": "1 through 10", "median_amount": 568.22, "10th_percentile": 568.22, "90th_percentile": 568.22 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 107.5, "standard_charge_algorithm": "Fee schedule rate ($107.50).", "count": "1 through 10", "median_amount": 74.25, "10th_percentile": 74.25, "90th_percentile": 74.25 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 681.06, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 696.04, "10th_percentile": 640.66, "90th_percentile": 696.04 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 681.06, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 681.06, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 681.06, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 669.27, "10th_percentile": 669.27, "90th_percentile": 669.27 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 681.06, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 696.04, "10th_percentile": 696.04, "90th_percentile": 696.04 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 701.49, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 681.06, "standard_charge_algorithm": "APC Price ($681.06). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 107.5, "maximum": 5649.04, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Perq Clsr Tcat L Atr Apndge W/Endocardial Implnt", "code_information": [ { "code": "CASE-33340", "type": "LOCAL" }, { "code": "33340", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 36407.43, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 135.93, "standard_charge_algorithm": "APC Rate ($135.93). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 135.93, "standard_charge_algorithm": "APC Rate ($135.93). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 578.99 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 810.59 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 16500.0, "standard_charge_algorithm": "Case rate ($16,500). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 1447.48 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 578.99 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 1157.98 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 578.99 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 578.99 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 655.94, "standard_charge_algorithm": "Fee schedule rate ($655.94).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 655.94, "standard_charge_algorithm": "Fee schedule rate ($655.94).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 602.15, "standard_charge_algorithm": "Fee schedule rate ($602.15).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 578.99 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 578.99, "standard_charge_algorithm": "Fee schedule rate ($578.99).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 578.99, "standard_charge_algorithm": "Fee schedule rate ($578.99).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 578.99 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 596.36 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 578.99, "standard_charge_algorithm": "Fee schedule rate ($578.99).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 135.93, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Dir Rpr Ruptd Aneurysm Radial/Ulnar Artery", "code_information": [ { "code": "CASE-35045", "type": "LOCAL" }, { "code": "35045", "type": "CPT" }, { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6388.3, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7492.46, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13379.39, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10703.51, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 19067.93, "standard_charge_algorithm": "Case rate ($19,067.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 21928.44, "standard_charge_algorithm": "Case rate ($21,928.44). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 13135.26, "standard_charge_algorithm": "Case rate ($13,135.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10351.71, "standard_charge_algorithm": "Case rate ($10,351.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 10351.71, "standard_charge_algorithm": "Case rate ($10,351.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 10351.71, "standard_charge_algorithm": "Case rate ($10,351.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 818.0, "standard_charge_algorithm": "Fee schedule rate ($818).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 818.0, "standard_charge_algorithm": "Fee schedule rate ($818).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 5142.01, "10th_percentile": 5142.01, "90th_percentile": 5142.01 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5512.31, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 818.0, "maximum": 21928.44, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Rpr Acquired/Traumatic Av Fistula Extremities", "code_information": [ { "code": "CASE-35190", "type": "LOCAL" }, { "code": "35190", "type": "CPT" }, { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7003.46, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7492.46, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13379.39, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10703.51, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 19067.93, "standard_charge_algorithm": "Case rate ($19,067.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 21928.44, "standard_charge_algorithm": "Case rate ($21,928.44). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 13135.26, "standard_charge_algorithm": "Case rate ($13,135.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10351.71, "standard_charge_algorithm": "Case rate ($10,351.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 10351.71, "standard_charge_algorithm": "Case rate ($10,351.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 10351.71, "standard_charge_algorithm": "Case rate ($10,351.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5010.85, "standard_charge_algorithm": "Case rate ($5,010.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5010.85, "standard_charge_algorithm": "Case rate ($5,010.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5512.31, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 5010.85, "maximum": 21928.44, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Injection Rx Extremity Pseudoaneurysm", "code_information": [ { "code": "CASE-36002", "type": "LOCAL" }, { "code": "36002", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2251.07, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 640.89, "standard_charge_algorithm": "APC Rate ($640.89). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 640.89, "standard_charge_algorithm": "APC Rate ($640.89). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 844.65, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 1738.26, "standard_charge_algorithm": "Case rate ($1,738.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1508.3, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1206.64, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 567.54, "standard_charge_algorithm": "Case rate ($567.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 567.54, "standard_charge_algorithm": "Case rate ($567.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 567.54, "standard_charge_algorithm": "Case rate ($567.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 567.54, "standard_charge_algorithm": "Case rate ($567.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 567.54, "standard_charge_algorithm": "Case rate ($567.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 567.54, "standard_charge_algorithm": "Case rate ($567.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 130.19, "standard_charge_algorithm": "Fee schedule rate ($130.19).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 130.19, "standard_charge_algorithm": "Fee schedule rate ($130.19).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 621.42, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 130.19, "maximum": 1738.26, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Injection Proc,Extremity,Venography", "code_information": [ { "code": "CASE-36005", "type": "LOCAL" }, { "code": "36005", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4047.75, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1608.25, "standard_charge_algorithm": "APC Rate ($1,608.25). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1608.25, "standard_charge_algorithm": "APC Rate ($1,608.25). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1513.97, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2119.56, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 594.35, "standard_charge_algorithm": "Case rate ($594.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3784.94, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1513.97, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3027.95, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 805.81, "standard_charge_algorithm": "Case rate ($805.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1513.97, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 805.81, "standard_charge_algorithm": "Case rate ($805.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 805.81, "standard_charge_algorithm": "Case rate ($805.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 805.81, "standard_charge_algorithm": "Case rate ($805.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 805.81, "standard_charge_algorithm": "Case rate ($805.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 805.81, "standard_charge_algorithm": "Case rate ($805.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1513.97, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 52.33, "standard_charge_algorithm": "Fee schedule rate ($52.33).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 52.33, "standard_charge_algorithm": "Fee schedule rate ($52.33).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1513.97, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1513.97, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1513.97, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1513.97, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1513.97, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1559.39, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1513.97, "standard_charge_algorithm": "APC Price ($1,513.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 52.33, "maximum": 3784.94, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Place Cath in Vein,Svc,Ivc", "code_information": [ { "code": "CASE-36010", "type": "LOCAL" }, { "code": "36010", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 8007.04, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 2455.3, "standard_charge_algorithm": "Case rate ($2,455.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1052.55, "standard_charge_algorithm": "Fee schedule rate ($1,052.55).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1052.55, "standard_charge_algorithm": "Fee schedule rate ($1,052.55).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1052.55, "maximum": 13684.94, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Place Cath in Vein,Subselect", "code_information": [ { "code": "CASE-36012", "type": "LOCAL" }, { "code": "36012", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7243.47, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 2062.36, "standard_charge_algorithm": "Case rate ($2,062.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1052.55, "standard_charge_algorithm": "Fee schedule rate ($1,052.55).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1052.55, "standard_charge_algorithm": "Fee schedule rate ($1,052.55).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1052.55, "maximum": 13684.94, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Place Cath Extrem Artery", "code_information": [ { "code": "CASE-36140", "type": "LOCAL" }, { "code": "36140", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9694.19, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 15543.99, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 1029.68, "standard_charge_algorithm": "Case rate ($1,029.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 27757.13, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 22205.7, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 1250.94, "standard_charge_algorithm": "Fee schedule rate ($1,250.94).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2114.59, "standard_charge_algorithm": "Fee schedule rate ($2,114.59).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2114.59, "standard_charge_algorithm": "Fee schedule rate ($2,114.59).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11435.94, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1029.68, "maximum": 27757.13, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Place Cath Aorta", "code_information": [ { "code": "CASE-36200", "type": "LOCAL" }, { "code": "36200", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5704.0, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 1314.6, "10th_percentile": 1314.6, "90th_percentile": 1314.6 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 1835.7, "standard_charge_algorithm": "Case rate ($1,835.70). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 57.7, "standard_charge_algorithm": "Fee schedule rate ($57.70).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 57.7, "standard_charge_algorithm": "Fee schedule rate ($57.70).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 57.7, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Place Cath Selective Art,Neck", "code_information": [ { "code": "CASE-36215", "type": "LOCAL" }, { "code": "36215", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 15375.54, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 2109.71, "standard_charge_algorithm": "Case rate ($2,109.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 335.27, "standard_charge_algorithm": "Fee schedule rate ($335.27).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 335.27, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Place Cath Select Art,Abd/Pel", "code_information": [ { "code": "CASE-36245", "type": "LOCAL" }, { "code": "36245", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9656.79, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 5000.0, "standard_charge_algorithm": "Fee schedule rate ($5,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4365.19, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 2184.38, "standard_charge_algorithm": "Case rate ($2,184.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7794.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6235.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 342.48, "standard_charge_algorithm": "Fee schedule rate ($342.48).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2919.38, "standard_charge_algorithm": "Case rate ($2,919.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2919.38, "standard_charge_algorithm": "Case rate ($2,919.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3211.53, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 342.48, "maximum": 29605.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Place Cath Subselect Art,Abd/Pel", "code_information": [ { "code": "CASE-36246", "type": "LOCAL" }, { "code": "36246", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6781.9, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 4527.16, "standard_charge_algorithm": "Case rate ($4,527.16). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 57.7, "standard_charge_algorithm": "Fee schedule rate ($57.70).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 57.7, "standard_charge_algorithm": "Fee schedule rate ($57.70).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 57.7, "maximum": 29605.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Place Cath Subsubselect Art,Abd/Pel", "code_information": [ { "code": "CASE-36247", "type": "LOCAL" }, { "code": "36247", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7267.55, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 4888.58, "standard_charge_algorithm": "Case rate ($4,888.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 57.7, "standard_charge_algorithm": "Fee schedule rate ($57.70).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 57.7, "standard_charge_algorithm": "Fee schedule rate ($57.70).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 57.7, "maximum": 29605.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Slctv Cathj Ea 2nd+ Ord Abdl Pel/Lxtr Art Brnch", "code_information": [ { "code": "CASE-36248", "type": "LOCAL" }, { "code": "36248", "type": "CPT" }, { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 26964.24, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 24683.14, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 708.75, "standard_charge_algorithm": "Case rate ($708.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 44077.04, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35261.63, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5423.34, "standard_charge_algorithm": "Fee schedule rate ($5,423.34).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5423.34, "standard_charge_algorithm": "Fee schedule rate ($5,423.34).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 18159.74, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 708.75, "maximum": 44077.04, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Slctv Cath 1stord W/WO Art Punct/Fluoro/S&I Uni", "code_information": [ { "code": "CASE-36251", "type": "LOCAL" }, { "code": "36251", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 14698.05, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 15543.99, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 5711.83, "standard_charge_algorithm": "Case rate ($5,711.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 27757.13, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 22205.7, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11435.94, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 2843.33, "maximum": 27757.13, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Slctv Cath 1stord W/WO Art Punct/Fluor/S&I Bilat", "code_information": [ { "code": "CASE-36252", "type": "LOCAL" }, { "code": "36252", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 17169.96, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 15543.99, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 14811.66, "standard_charge_algorithm": "Case rate ($14,811.66). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 27757.13, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 22205.7, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6850.08, "standard_charge_algorithm": "Case rate ($6,850.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1091.42, "standard_charge_algorithm": "Fee schedule rate ($1,091.42).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1091.42, "standard_charge_algorithm": "Fee schedule rate ($1,091.42).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11435.94, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1091.42, "maximum": 27757.13, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Chg Collection Venous Blood,Venipuncture - Draw Charge", "code_information": [ { "code": "CASE-36415", "type": "LOCAL" }, { "code": "36415", "type": "CPT" }, { "code": "300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 211.62, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "56", "median_amount": 17.74, "10th_percentile": 15.98, "90th_percentile": 17.74 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 9.45, "10th_percentile": 9.45, "90th_percentile": 9.45 }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "35", "median_amount": 8.14, "10th_percentile": 7.07, "90th_percentile": 8.85 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "16", "median_amount": 9.09, "10th_percentile": 9.09, "90th_percentile": 16.36 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "396", "median_amount": 9.09, "10th_percentile": 8.83, "90th_percentile": 17.12 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "21", "median_amount": 11.82, "10th_percentile": 11.82, "90th_percentile": 11.82 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 9.09, "10th_percentile": 8.83, "90th_percentile": 22.82 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 117.18, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "90", "median_amount": 12.73, "10th_percentile": 12.73, "90th_percentile": 12.73 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "1 through 10", "median_amount": 25.63, "10th_percentile": 25.63, "90th_percentile": 25.63 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 396.22, "10th_percentile": 352.87, "90th_percentile": 396.22 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 209.25, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "1 through 10", "median_amount": 22.73, "10th_percentile": 22.73, "90th_percentile": 22.73 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "20", "median_amount": 9.09, "10th_percentile": 9.09, "90th_percentile": 9.09 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "1 through 10", "median_amount": 12.73, "10th_percentile": 12.73, "90th_percentile": 12.73 }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "1 through 10", "median_amount": 6.36, "10th_percentile": 6.36, "90th_percentile": 6.36 }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 167.4, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 3.61, "standard_charge_algorithm": "Fee schedule rate ($3.61).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 9.82, "10th_percentile": 6.23, "90th_percentile": 9.82 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "120", "median_amount": 9.09, "10th_percentile": 9.09, "90th_percentile": 9.09 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 8.31, "standard_charge_algorithm": "Fee schedule rate ($8.31).", "count": "64", "median_amount": 15.7, "10th_percentile": 7.85, "90th_percentile": 39.25 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 8.31, "standard_charge_algorithm": "Fee schedule rate ($8.31).", "count": "278", "median_amount": 8.09, "10th_percentile": 8.09, "90th_percentile": 8.09 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "76", "median_amount": 9.45, "10th_percentile": 9.45, "90th_percentile": 9.45 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "665", "median_amount": 9.09, "10th_percentile": 9.09, "90th_percentile": 9.09 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1541", "median_amount": 9.09, "10th_percentile": 9.09, "90th_percentile": 9.09 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "23", "median_amount": 9.45, "10th_percentile": 9.45, "90th_percentile": 9.45 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 86.21, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 9.09, "10th_percentile": 9.09, "90th_percentile": 9.09 } ], "minimum": 3.61, "maximum": 209.25, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Collection Capillary Blood Specimen - Bundled Charge", "code_information": [ { "code": "CASE-36416", "type": "LOCAL" }, { "code": "36416", "type": "CPT" }, { "code": "300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7602.54, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 7000.0, "standard_charge_algorithm": "Fee schedule rate ($7,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 11.4, "10th_percentile": 8.29, "90th_percentile": 28.09 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "15", "median_amount": 15.77, "10th_percentile": 7.19, "90th_percentile": 103.53 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 50964.65, "standard_charge_algorithm": "Case rate ($50,964.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 58610.21, "standard_charge_algorithm": "Case rate ($58,610.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 35107.84, "standard_charge_algorithm": "Case rate ($35,107.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5125.28, "standard_charge_algorithm": "Case rate ($5,125.28). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5125.28, "standard_charge_algorithm": "Case rate ($5,125.28). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "1 through 10", "median_amount": 44.15, "10th_percentile": 17.92, "90th_percentile": 44.15 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 44.15, "10th_percentile": 17.92, "90th_percentile": 44.15 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 5125.28, "maximum": 58610.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Blood Transfusion Service", "code_information": [ { "code": "CASE-36430", "type": "LOCAL" }, { "code": "36430", "type": "CPT" }, { "code": "391", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5097.23, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2672.15, "standard_charge_algorithm": "APC Rate ($2,672.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2672.15, "standard_charge_algorithm": "APC Rate ($2,672.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3521.71, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 582.19, "10th_percentile": 582.19, "90th_percentile": 582.19 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6288.77, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5031.02, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 4947.22, "standard_charge_algorithm": "Case rate ($4,947.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2518.57, "standard_charge_algorithm": "APC Price ($2,518.57). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 5689.39, "standard_charge_algorithm": "Case rate ($5,689.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 3407.97, "standard_charge_algorithm": "Case rate ($3,407.97). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2685.78, "standard_charge_algorithm": "Case rate ($2,685.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2685.78, "standard_charge_algorithm": "Case rate ($2,685.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2685.78, "standard_charge_algorithm": "Case rate ($2,685.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 397.28, "standard_charge_algorithm": "Fee schedule rate ($397.28).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 397.28, "standard_charge_algorithm": "Fee schedule rate ($397.28).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 415.85, "10th_percentile": 415.85, "90th_percentile": 415.85 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 415.85, "10th_percentile": 415.85, "90th_percentile": 415.85 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2590.97, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 397.28, "maximum": 6288.77, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Spider Vein(S) Liquid Sclerotherapy", "code_information": [ { "code": "CASE-36468", "type": "LOCAL" }, { "code": "36468", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1009.86, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 2286.0, "standard_charge_algorithm": "Case rate ($2,286). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 415.32, "standard_charge_algorithm": "APC Rate ($415.32). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 415.32, "standard_charge_algorithm": "APC Rate ($415.32). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 390.97, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 547.36, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 800.0, "standard_charge_algorithm": "Case rate ($800). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 977.43, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 390.97, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 781.95, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 2066.09, "standard_charge_algorithm": "Case rate ($2,066.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 390.97, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 2376.03, "standard_charge_algorithm": "Case rate ($2,376.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 1423.26, "standard_charge_algorithm": "Case rate ($1,423.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 390.97, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 390.97, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 390.97, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 390.97, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 390.97, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 390.97, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 402.7, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 390.97, "standard_charge_algorithm": "APC Price ($390.97). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 390.97, "maximum": 2376.03, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Injection Therapy Vein,One Vein", "code_information": [ { "code": "CASE-36470", "type": "LOCAL" }, { "code": "36470", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4588.95, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 1006.35, "standard_charge_algorithm": "Case rate ($1,006.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "per diem", "standard_charge_dollar": 13846.6, "standard_charge_algorithm": "Per diem ($13,846.60). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "per diem", "standard_charge_dollar": 15923.82, "standard_charge_algorithm": "Per diem ($15,923.82). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "per diem", "standard_charge_dollar": 9538.46, "standard_charge_algorithm": "Per diem ($9,538.46). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "per diem", "standard_charge_dollar": 7517.12, "standard_charge_algorithm": "Per diem ($7,517.12). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "per diem", "standard_charge_dollar": 7517.12, "standard_charge_algorithm": "Per diem ($7,517.12). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "per diem", "standard_charge_dollar": 7517.12, "standard_charge_algorithm": "Per diem ($7,517.12). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 95.47, "standard_charge_algorithm": "Fee schedule rate ($95.47).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 95.47, "standard_charge_algorithm": "Fee schedule rate ($95.47).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 95.47, "maximum": 15923.82, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Injection Therapy Vein,Mult Veins", "code_information": [ { "code": "CASE-36471", "type": "LOCAL" }, { "code": "36471", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4714.76, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 626.61, "standard_charge_algorithm": "Case rate ($626.61). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 2066.09, "standard_charge_algorithm": "Case rate ($2,066.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 2376.03, "standard_charge_algorithm": "Case rate ($2,376.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 1423.26, "standard_charge_algorithm": "Case rate ($1,423.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 380.04, "10th_percentile": 380.04, "90th_percentile": 380.04 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 626.61, "maximum": 7591.92, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Endovenous Rf, 1st Vein", "code_information": [ { "code": "CASE-36475", "type": "LOCAL" }, { "code": "36475", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6281.45, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1754.0, "standard_charge_algorithm": "Case rate ($1,754). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 13950.88, "standard_charge_algorithm": "Case rate ($13,950.88). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "per diem", "standard_charge_dollar": 13846.6, "standard_charge_algorithm": "Per diem ($13,846.60). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "per diem", "standard_charge_dollar": 15923.82, "standard_charge_algorithm": "Per diem ($15,923.82). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "per diem", "standard_charge_dollar": 9538.46, "standard_charge_algorithm": "Per diem ($9,538.46). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "per diem", "standard_charge_dollar": 7517.12, "standard_charge_algorithm": "Per diem ($7,517.12). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "per diem", "standard_charge_dollar": 7517.12, "standard_charge_algorithm": "Per diem ($7,517.12). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "per diem", "standard_charge_dollar": 7517.12, "standard_charge_algorithm": "Per diem ($7,517.12). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "20", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1754.0, "maximum": 15923.82, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Endovenous Rf, Vein Add-On", "code_information": [ { "code": "CASE-36476", "type": "LOCAL" }, { "code": "36476", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 8235.58, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 7021.15, "standard_charge_algorithm": "Case rate ($7,021.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 12813.56, "standard_charge_algorithm": "Case rate ($12,813.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 14735.8, "standard_charge_algorithm": "Case rate ($14,735.80). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 8826.83, "standard_charge_algorithm": "Case rate ($8,826.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1143.0, "maximum": 14735.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Endovenous Laser, 1st Vein", "code_information": [ { "code": "CASE-36478", "type": "LOCAL" }, { "code": "36478", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5918.89, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1754.0, "standard_charge_algorithm": "Case rate ($1,754). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 8614.82, "standard_charge_algorithm": "Case rate ($8,614.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 12813.56, "standard_charge_algorithm": "Case rate ($12,813.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 14735.8, "standard_charge_algorithm": "Case rate ($14,735.80). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 8826.83, "standard_charge_algorithm": "Case rate ($8,826.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "51", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1754.0, "maximum": 14735.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Endovenous Laser Vein Addon", "code_information": [ { "code": "CASE-36479", "type": "LOCAL" }, { "code": "36479", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6343.52, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 6009.86, "standard_charge_algorithm": "Case rate ($6,009.86). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 12813.56, "standard_charge_algorithm": "Case rate ($12,813.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 14735.8, "standard_charge_algorithm": "Case rate ($14,735.80). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 8826.83, "standard_charge_algorithm": "Case rate ($8,826.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1143.0, "maximum": 14735.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Venaseal Rfa, 1st Vein", "code_information": [ { "code": "CASE-36482", "type": "LOCAL" }, { "code": "36482", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6864.25, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1754.0, "standard_charge_algorithm": "Case rate ($1,754). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7492.46, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 12021.93, "standard_charge_algorithm": "Case rate ($12,021.93). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13379.39, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10703.51, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "per diem", "standard_charge_dollar": 13846.6, "standard_charge_algorithm": "Per diem ($13,846.60). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "per diem", "standard_charge_dollar": 15923.82, "standard_charge_algorithm": "Per diem ($15,923.82). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "per diem", "standard_charge_dollar": 9538.46, "standard_charge_algorithm": "Per diem ($9,538.46). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "per diem", "standard_charge_dollar": 7517.12, "standard_charge_algorithm": "Per diem ($7,517.12). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "per diem", "standard_charge_dollar": 7517.12, "standard_charge_algorithm": "Per diem ($7,517.12). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "per diem", "standard_charge_dollar": 7517.12, "standard_charge_algorithm": "Per diem ($7,517.12). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 366.07, "standard_charge_algorithm": "Case rate ($366.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 366.07, "standard_charge_algorithm": "Case rate ($366.07). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "32", "median_amount": 5142.01, "10th_percentile": 4811.5, "90th_percentile": 5142.01 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5512.31, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 366.07, "maximum": 15923.82, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Venaseal Rfa, Addt'l Vein", "code_information": [ { "code": "CASE-36483", "type": "LOCAL" }, { "code": "36483", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 8419.08, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7492.46, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 6019.78, "standard_charge_algorithm": "Case rate ($6,019.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13379.39, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10703.51, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 12813.56, "standard_charge_algorithm": "Case rate ($12,813.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 14735.8, "standard_charge_algorithm": "Case rate ($14,735.80). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 8826.83, "standard_charge_algorithm": "Case rate ($8,826.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 6956.3, "standard_charge_algorithm": "Case rate ($6,956.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 0.01, "standard_charge_algorithm": "Fee schedule rate ($0.01).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 0.01, "standard_charge_algorithm": "Fee schedule rate ($0.01).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5512.31, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 0.01, "maximum": 14735.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Removal Tunneled Cv Cath W Subq Port or Pump", "code_information": [ { "code": "CASE-36590", "type": "LOCAL" }, { "code": "36590", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 35530.91, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 25165.0, "standard_charge_algorithm": "Case rate ($25,165).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 32068.73, "standard_charge_algorithm": "APC Rate ($32,068.73). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 32068.73, "standard_charge_algorithm": "APC Rate ($32,068.73). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 42264.41, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 934.2, "standard_charge_algorithm": "Case rate ($934.20). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 75472.15, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 60377.72, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 128156.22, "standard_charge_algorithm": "Case rate ($128,156.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 147381.81, "standard_charge_algorithm": "Case rate ($147,381.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 88282.52, "standard_charge_algorithm": "Case rate ($88,282.52). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 69574.21, "standard_charge_algorithm": "Case rate ($69,574.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 69574.21, "standard_charge_algorithm": "Case rate ($69,574.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 69574.21, "standard_charge_algorithm": "Case rate ($69,574.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 28265.83, "standard_charge_algorithm": "Case rate ($28,265.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 28265.83, "standard_charge_algorithm": "Case rate ($28,265.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 31094.53, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 30188.86, "standard_charge_algorithm": "APC Price ($30,188.86). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 934.2, "maximum": 147381.81, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Arterial Puncture", "code_information": [ { "code": "CASE-36600", "type": "LOCAL" }, { "code": "36600", "type": "CPT" }, { "code": "410", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1342.57, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 558.25, "standard_charge_algorithm": "APC Rate ($558.25). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 558.25, "standard_charge_algorithm": "APC Rate ($558.25). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 735.74, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1313.81, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1051.05, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 23.14, "standard_charge_algorithm": "Fee schedule rate ($23.14).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 23.14, "standard_charge_algorithm": "Fee schedule rate ($23.14).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 541.29, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 23.14, "maximum": 1313.81, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Prim Prq Trluml Mchnl Thrmbc N-Cor N-Icra 1st", "code_information": [ { "code": "CASE-37184", "type": "LOCAL" }, { "code": "37184", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23065.54, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 24683.14, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 10001.29, "standard_charge_algorithm": "Case rate ($10,001.29). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 44077.04, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35261.63, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1339.68, "standard_charge_algorithm": "Fee schedule rate ($1,339.68).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1339.68, "standard_charge_algorithm": "Fee schedule rate ($1,339.68).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 18159.74, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1339.68, "maximum": 44077.04, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Prim Prq Trluml Mchnl Thrmbc N-Cor N-Icra Sbsq", "code_information": [ { "code": "CASE-37185", "type": "LOCAL" }, { "code": "37185", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 28395.59, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 5000.0, "standard_charge_algorithm": "Fee schedule rate ($5,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 24683.14, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 18939.94, "standard_charge_algorithm": "Case rate ($18,939.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 44077.04, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35261.63, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 377.48, "standard_charge_algorithm": "Fee schedule rate ($377.48).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 377.48, "standard_charge_algorithm": "Fee schedule rate ($377.48).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 18159.74, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 377.48, "maximum": 44077.04, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Tcat IV Stent Crv Crtd Art Embolic Protecj", "code_information": [ { "code": "CASE-37215", "type": "LOCAL" }, { "code": "37215", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 18823.83, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1754.0, "standard_charge_algorithm": "Case rate ($1,754). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 217.31, "standard_charge_algorithm": "APC Rate ($217.31). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 217.31, "standard_charge_algorithm": "APC Rate ($217.31). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 838.26 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 1173.56 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 17340.56, "standard_charge_algorithm": "Case rate ($17,340.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 2095.65 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 838.26 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 1676.52 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 838.26 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 838.26 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 830.7, "standard_charge_algorithm": "Fee schedule rate ($830.70).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 830.7, "standard_charge_algorithm": "Fee schedule rate ($830.70).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 871.79, "standard_charge_algorithm": "Fee schedule rate ($871.79).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 838.26 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 8370.0, "standard_charge_algorithm": "Case rate ($8,370). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 838.26, "standard_charge_algorithm": "Fee schedule rate ($838.26).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 838.26 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 863.41 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 838.26, "standard_charge_algorithm": "Fee schedule rate ($838.26).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 217.31, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Vasc Revascularize Iliac Artery,Angioplasty, Initial Vessel", "code_information": [ { "code": "CASE-37220", "type": "LOCAL" }, { "code": "37220", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10902.13, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 44177.59, "standard_charge_algorithm": "Case rate ($44,177.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 65.55, "standard_charge_algorithm": "Fee schedule rate ($65.55).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 65.55, "standard_charge_algorithm": "Fee schedule rate ($65.55).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 9632.15, "10th_percentile": 5423.4, "90th_percentile": 9632.15 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 65.55, "maximum": 44177.59, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Revascularize Iliac Artery,Angioplasty/Stent, Initial Vessel", "code_information": [ { "code": "CASE-37221", "type": "LOCAL" }, { "code": "37221", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 18812.34, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 79.43, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 22590.25, "standard_charge_algorithm": "Case rate ($22,590.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 141.84, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 113.47, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 41.23, "standard_charge_algorithm": "Fee schedule rate ($41.23).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 41.23, "standard_charge_algorithm": "Fee schedule rate ($41.23).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 10787.38, "10th_percentile": 9632.15, "90th_percentile": 10787.38 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 58.44, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 41.23, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Vasc Revascularize Iliac Artery,Angioplasty/Stent, Ea Add Vessel", "code_information": [ { "code": "CASE-37223", "type": "LOCAL" }, { "code": "37223", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 16603.82, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 117.18, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 12020.99, "standard_charge_algorithm": "Case rate ($12,020.99). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 209.25, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 167.4, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "standard_charge_algorithm": "Fee schedule rate ($18.87).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "standard_charge_algorithm": "Fee schedule rate ($18.87).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 86.21, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 18.87, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Vasc Revascularize Fem/Pop Artery,Angioplasty", "code_information": [ { "code": "CASE-37224", "type": "LOCAL" }, { "code": "37224", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 13009.75, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 79.43, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 16553.71, "standard_charge_algorithm": "Case rate ($16,553.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 141.84, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 113.47, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 41.23, "standard_charge_algorithm": "Fee schedule rate ($41.23).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 41.23, "standard_charge_algorithm": "Fee schedule rate ($41.23).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 5423.4, "10th_percentile": 5423.4, "90th_percentile": 10787.38 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 58.44, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 41.23, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Vasc Revascularize Fem/Pop Artery,Angioplasty/Atherectomy", "code_information": [ { "code": "CASE-37225", "type": "LOCAL" }, { "code": "37225", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 22744.61, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 35198.59, "standard_charge_algorithm": "Case rate ($35,198.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 54.46, "standard_charge_algorithm": "Fee schedule rate ($54.46).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 54.46, "standard_charge_algorithm": "Fee schedule rate ($54.46).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 17080.79, "10th_percentile": 17080.79, "90th_percentile": 17080.79 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 54.46, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Vasc Revascularize Fem/Pop Artery,Angioplasty/Stent", "code_information": [ { "code": "CASE-37226", "type": "LOCAL" }, { "code": "37226", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 21711.71, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 79.43, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 36424.98, "standard_charge_algorithm": "Case rate ($36,424.98). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 141.84, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 113.47, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 41.23, "standard_charge_algorithm": "Fee schedule rate ($41.23).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 41.23, "standard_charge_algorithm": "Fee schedule rate ($41.23).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 58.44, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 41.23, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Vasc Revascularize Fem/Pop Artery,Angioplasty/Stent/Atherectomy", "code_information": [ { "code": "CASE-37227", "type": "LOCAL" }, { "code": "37227", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 27176.49, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "standard_charge_algorithm": "Fee schedule rate ($13.73).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "standard_charge_algorithm": "Fee schedule rate ($13.73).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 13.73 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 19.22 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 63710.49, "standard_charge_algorithm": "Case rate ($63,710.49). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 34.33 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 13.73 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 27.46 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 13.73 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.73 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 12.21, "standard_charge_algorithm": "Fee schedule rate ($12.21).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 12.21, "standard_charge_algorithm": "Fee schedule rate ($12.21).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 14.28, "standard_charge_algorithm": "Fee schedule rate ($14.28).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.73 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "standard_charge_algorithm": "Fee schedule rate ($13.73).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "standard_charge_algorithm": "Fee schedule rate ($13.73).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.73 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 14.14 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.73, "standard_charge_algorithm": "Fee schedule rate ($13.73).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 12.21, "maximum": 63710.49, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Vasc Revascularize Tibial/Peron Artery,Angioplasty Initial", "code_information": [ { "code": "CASE-37228", "type": "LOCAL" }, { "code": "37228", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 17042.29, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 79.43, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 18939.94, "standard_charge_algorithm": "Case rate ($18,939.94). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 141.84, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 113.47, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 41.23, "standard_charge_algorithm": "Fee schedule rate ($41.23).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 41.23, "standard_charge_algorithm": "Fee schedule rate ($41.23).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 10787.38, "10th_percentile": 10787.38, "90th_percentile": 10787.38 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 58.44, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 41.23, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Open/Perq Placement Intravascular Stent Initial", "code_information": [ { "code": "CASE-37236", "type": "LOCAL" }, { "code": "37236", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 17584.29, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 26644.34, "10th_percentile": 26644.34, "90th_percentile": 26644.34 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 15543.99, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 21512.22, "standard_charge_algorithm": "Case rate ($21,512.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 27757.13, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 22205.7, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2114.59, "standard_charge_algorithm": "Fee schedule rate ($2,114.59).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2114.59, "standard_charge_algorithm": "Fee schedule rate ($2,114.59).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 10787.38, "10th_percentile": 9632.15, "90th_percentile": 10787.38 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11435.94, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 2114.59, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Open/Perq Placement Intravascular Stent Ea Addl", "code_information": [ { "code": "CASE-37237", "type": "LOCAL" }, { "code": "37237", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 17979.71, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 15543.99, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 9681.54, "standard_charge_algorithm": "Case rate ($9,681.54). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 27757.13, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 22205.7, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 999.16, "standard_charge_algorithm": "Fee schedule rate ($999.16).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 999.16, "standard_charge_algorithm": "Fee schedule rate ($999.16).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11435.94, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 999.16, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Vasc Vascular Embolization or Occlusion Arterial Rs&I", "code_information": [ { "code": "CASE-37242", "type": "LOCAL" }, { "code": "37242", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 16617.44, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 24683.14, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 18107.75, "standard_charge_algorithm": "Case rate ($18,107.75). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 44077.04, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35261.63, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5423.34, "standard_charge_algorithm": "Fee schedule rate ($5,423.34).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5423.34, "standard_charge_algorithm": "Fee schedule rate ($5,423.34).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 8540.4, "10th_percentile": 8540.4, "90th_percentile": 8540.4 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 18159.74, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 5423.34, "maximum": 44077.04, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Trlml Balo Angiop Open/Perq W/Img S&I 1st Vein", "code_information": [ { "code": "CASE-37248", "type": "LOCAL" }, { "code": "37248", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 8007.04, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 3417.0, "standard_charge_algorithm": "Case rate ($3,417). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 9027.27, "standard_charge_algorithm": "Case rate ($9,027.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1052.55, "standard_charge_algorithm": "Fee schedule rate ($1,052.55).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1052.55, "standard_charge_algorithm": "Fee schedule rate ($1,052.55).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1052.55, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Intravascular US Noncoronary Rs&I Intial Vessel", "code_information": [ { "code": "CASE-37252", "type": "LOCAL" }, { "code": "37252", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9338.81, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 1150.57, "standard_charge_algorithm": "Case rate ($1,150.57). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 722.89, "standard_charge_algorithm": "Fee schedule rate ($722.89).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 722.89, "standard_charge_algorithm": "Fee schedule rate ($722.89).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 341.38, "maximum": 13684.94, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Ligation/Biopsy Temporal Artery", "code_information": [ { "code": "CASE-37609", "type": "LOCAL" }, { "code": "37609", "type": "CPT" }, { "code": "450", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3956.87, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1532.0, "standard_charge_algorithm": "Case rate ($1,532). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1687.37, "standard_charge_algorithm": "APC Rate ($1,687.37). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1687.37, "standard_charge_algorithm": "APC Rate ($1,687.37). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2223.84, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3971.14, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3176.91, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 4912.14, "standard_charge_algorithm": "Case rate ($4,912.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 5649.04, "standard_charge_algorithm": "Case rate ($5,649.04). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 3383.81, "standard_charge_algorithm": "Case rate ($3,383.81). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2666.73, "standard_charge_algorithm": "Case rate ($2,666.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2666.73, "standard_charge_algorithm": "Case rate ($2,666.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2666.73, "standard_charge_algorithm": "Case rate ($2,666.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1487.27, "standard_charge_algorithm": "Case rate ($1,487.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1487.27, "standard_charge_algorithm": "Case rate ($1,487.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1636.11, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1588.46, "standard_charge_algorithm": "APC Price ($1,588.46). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1487.27, "maximum": 5649.04, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Phleb Veins - Extrem - to 20", "code_information": [ { "code": "CASE-37765", "type": "LOCAL" }, { "code": "37765", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4144.78, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1754.0, "standard_charge_algorithm": "Case rate ($1,754). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 8942.58, "standard_charge_algorithm": "Case rate ($8,942.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 2066.09, "standard_charge_algorithm": "Case rate ($2,066.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 2376.03, "standard_charge_algorithm": "Case rate ($2,376.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 1423.26, "standard_charge_algorithm": "Case rate ($1,423.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "20", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1121.65, "maximum": 8942.58, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Phleb Veins - Extrem 20+", "code_information": [ { "code": "CASE-37766", "type": "LOCAL" }, { "code": "37766", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4763.73, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1754.0, "standard_charge_algorithm": "Case rate ($1,754). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 10612.0, "standard_charge_algorithm": "Case rate ($10,612). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 2066.09, "standard_charge_algorithm": "Case rate ($2,066.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 2376.03, "standard_charge_algorithm": "Case rate ($2,376.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 1423.26, "standard_charge_algorithm": "Case rate ($1,423.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 1121.65, "standard_charge_algorithm": "Case rate ($1,121.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2843.33, "standard_charge_algorithm": "Case rate ($2,843.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "27", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1121.65, "maximum": 10612.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Mediastinoscopy Includes Mediastinal Mass Biopsy", "code_information": [ { "code": "CASE-39401", "type": "LOCAL" }, { "code": "39401", "type": "CPT" }, { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 9001.14, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1754.0, "standard_charge_algorithm": "Case rate ($1,754). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 6176.47, "standard_charge_algorithm": "APC Rate ($6,176.47). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 6176.47, "standard_charge_algorithm": "APC Rate ($6,176.47). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 8140.17, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 14536.01, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11628.81, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 5307.77, "standard_charge_algorithm": "Case rate ($5,307.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6104.03, "standard_charge_algorithm": "Case rate ($6,104.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 3656.35, "standard_charge_algorithm": "Case rate ($3,656.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2881.51, "standard_charge_algorithm": "Case rate ($2,881.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2881.51, "standard_charge_algorithm": "Case rate ($2,881.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2881.51, "standard_charge_algorithm": "Case rate ($2,881.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 262.61, "standard_charge_algorithm": "Fee schedule rate ($262.61).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 262.61, "standard_charge_algorithm": "Fee schedule rate ($262.61).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5988.84, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 262.61, "maximum": 14536.01, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Mediastinoscopy With Lymph Node Biopsy/Ies", "code_information": [ { "code": "CASE-39402", "type": "LOCAL" }, { "code": "39402", "type": "CPT" }, { "code": "360", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 8312.73, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1754.0, "standard_charge_algorithm": "Case rate ($1,754). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 6176.47, "standard_charge_algorithm": "APC Rate ($6,176.47). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 6176.47, "standard_charge_algorithm": "APC Rate ($6,176.47). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 8140.17, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 14536.01, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11628.81, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 5307.77, "standard_charge_algorithm": "Case rate ($5,307.77). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6104.03, "standard_charge_algorithm": "Case rate ($6,104.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 3656.35, "standard_charge_algorithm": "Case rate ($3,656.35). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2881.51, "standard_charge_algorithm": "Case rate ($2,881.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2881.51, "standard_charge_algorithm": "Case rate ($2,881.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2881.51, "standard_charge_algorithm": "Case rate ($2,881.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 342.76, "standard_charge_algorithm": "Fee schedule rate ($342.76).", "count": "1 through 10", "median_amount": 5119.1, "10th_percentile": 5119.1, "90th_percentile": 5119.1 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 342.76, "standard_charge_algorithm": "Fee schedule rate ($342.76).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5988.84, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5814.41, "standard_charge_algorithm": "APC Price ($5,814.41). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 342.76, "maximum": 14536.01, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Esophagogastroduodenoscopy Transoral Diagnostic - Egd", "code_information": [ { "code": "CASE-43235", "type": "LOCAL" }, { "code": "43235", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 17288.4, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 926.63, "standard_charge_algorithm": "APC Rate ($926.63). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 926.63, "standard_charge_algorithm": "APC Rate ($926.63). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 2202.77, "10th_percentile": 2202.77, "90th_percentile": 2202.77 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 872.31, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1221.24, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2180.78, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 872.31, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1744.62, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 2074.61, "standard_charge_algorithm": "Case rate ($2,074.61). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 872.31, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 2074.61, "standard_charge_algorithm": "Case rate ($2,074.61). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 2074.61, "standard_charge_algorithm": "Case rate ($2,074.61). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2074.61, "standard_charge_algorithm": "Case rate ($2,074.61). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2074.61, "standard_charge_algorithm": "Case rate ($2,074.61). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2074.61, "standard_charge_algorithm": "Case rate ($2,074.61). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 872.31, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 891.83, "10th_percentile": 891.83, "90th_percentile": 891.83 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 816.74, "standard_charge_algorithm": "Case rate ($816.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 816.74, "standard_charge_algorithm": "Case rate ($816.74). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 872.31, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 872.31, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 872.31, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 891.83, "10th_percentile": 891.83, "90th_percentile": 891.83 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 872.31, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 872.31, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 898.48, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 872.31, "standard_charge_algorithm": "APC Price ($872.31). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 816.74, "maximum": 2180.78, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "Colsc Flx W/Rmvl of Tumor Polyp Lesion Snare Tq", "code_information": [ { "code": "CASE-45385", "type": "LOCAL" }, { "code": "45385", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 11123.97, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1532.0, "standard_charge_algorithm": "Case rate ($1,532). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1222.56, "standard_charge_algorithm": "APC Rate ($1,222.56). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1222.56, "standard_charge_algorithm": "APC Rate ($1,222.56). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1150.89, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1611.25, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2877.23, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1150.89, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2301.79, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6016.83, "standard_charge_algorithm": "Case rate ($6,016.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1150.89, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 6919.46, "standard_charge_algorithm": "Case rate ($6,919.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 4144.79, "standard_charge_algorithm": "Case rate ($4,144.79). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3266.45, "standard_charge_algorithm": "Case rate ($3,266.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 3266.45, "standard_charge_algorithm": "Case rate ($3,266.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 3266.45, "standard_charge_algorithm": "Case rate ($3,266.45). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1150.89, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1077.58, "standard_charge_algorithm": "Case rate ($1,077.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 1077.58, "standard_charge_algorithm": "Case rate ($1,077.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1150.89, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1150.89, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1150.89, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1150.89, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1150.89, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1185.42, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1150.89, "standard_charge_algorithm": "APC Price ($1,150.89). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 1077.58, "maximum": 6919.46, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Insert,Non-Indwelling Bladder Catheter", "code_information": [ { "code": "CASE-51701", "type": "LOCAL" }, { "code": "51701", "type": "CPT" }, { "code": "761", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 15031.02, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 4596.0, "standard_charge_algorithm": "Case rate ($4,596). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 24683.14, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 44077.04, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35261.63, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 37.13, "standard_charge_algorithm": "Fee schedule rate ($37.13).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 37.13, "standard_charge_algorithm": "Fee schedule rate ($37.13).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 18159.74, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 37.13, "maximum": 44077.04, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Insert,Temp Indwelling Blad Cath,Simple", "code_information": [ { "code": "CASE-51702", "type": "LOCAL" }, { "code": "51702", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 41889.72, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 31086.0, "standard_charge_algorithm": "Case rate ($31,086).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 26703.99, "standard_charge_algorithm": "APC Rate ($26,703.99). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 26703.99, "standard_charge_algorithm": "APC Rate ($26,703.99). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35194.04, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 298.53, "standard_charge_algorithm": "Case rate ($298.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 62846.51, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 50277.2, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 97.34, "standard_charge_algorithm": "Fee schedule rate ($97.34).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "per diem", "standard_charge_dollar": 65249.06, "standard_charge_algorithm": "Per diem ($65,249.06). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "per diem", "standard_charge_dollar": 75037.52, "standard_charge_algorithm": "Per diem ($75,037.52). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "per diem", "standard_charge_dollar": 44947.89, "standard_charge_algorithm": "Per diem ($44,947.89). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 51.45, "standard_charge_algorithm": "Fee schedule rate ($51.45).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 51.45, "standard_charge_algorithm": "Fee schedule rate ($51.45).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25892.76, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 51.45, "maximum": 75037.52, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Insert,Temp Indwelling Blad Cath,Comp", "code_information": [ { "code": "CASE-51703", "type": "LOCAL" }, { "code": "51703", "type": "CPT" }, { "code": "361", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1877.96, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2672.15, "standard_charge_algorithm": "APC Rate ($2,672.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2672.15, "standard_charge_algorithm": "APC Rate ($2,672.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3521.71, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 381.15, "standard_charge_algorithm": "Case rate ($381.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6288.77, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5031.02, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 207.58, "standard_charge_algorithm": "Case rate ($207.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2518.57, "standard_charge_algorithm": "APC Price ($2,518.57). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 207.58, "standard_charge_algorithm": "Case rate ($207.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 207.58, "standard_charge_algorithm": "Case rate ($207.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 207.58, "standard_charge_algorithm": "Case rate ($207.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 207.58, "standard_charge_algorithm": "Case rate ($207.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 207.58, "standard_charge_algorithm": "Case rate ($207.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 115.87, "standard_charge_algorithm": "Case rate ($115.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 115.87, "standard_charge_algorithm": "Case rate ($115.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2590.97, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 115.87, "maximum": 6288.77, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Inject Anes/Steroid Plantar Common Digital Nerve", "code_information": [ { "code": "CASE-64455", "type": "LOCAL" }, { "code": "64455", "type": "CPT" }, { "code": "510", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 251.49, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 313.6, "standard_charge_algorithm": "APC Rate ($313.60). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 313.6, "standard_charge_algorithm": "APC Rate ($313.60). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 413.3, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 738.04, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 590.43, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 2915.32, "standard_charge_algorithm": "Case rate ($2,915.32). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 3352.67, "standard_charge_algorithm": "Case rate ($3,352.67). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 2008.27, "standard_charge_algorithm": "Case rate ($2,008.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 1582.69, "standard_charge_algorithm": "Case rate ($1,582.69). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 1582.69, "standard_charge_algorithm": "Case rate ($1,582.69). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 1582.69, "standard_charge_algorithm": "Case rate ($1,582.69). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 42.57, "standard_charge_algorithm": "Fee schedule rate ($42.57).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 42.57, "standard_charge_algorithm": "Fee schedule rate ($42.57).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 304.07, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 295.22, "standard_charge_algorithm": "APC Price ($295.22). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 42.57, "maximum": 3352.67, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC CT Scan,Head/Brain,W/O Contrast Matl - CT Head WO Contrast", "code_information": [ { "code": "CASE-70450", "type": "LOCAL" }, { "code": "70450", "type": "CPT" }, { "code": "351", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 777.78, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "fee schedule", "standard_charge_dollar": 96.59, "standard_charge_algorithm": "Case rate ($96.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "fee schedule", "standard_charge_dollar": 96.59, "standard_charge_algorithm": "Case rate ($96.59). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 270.32, "standard_charge_algorithm": "Fee schedule rate ($270.32).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 102.62, "standard_charge_algorithm": "Fee schedule rate ($102.62).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 106.81, "standard_charge_algorithm": "APC Rate ($106.81). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 106.81, "standard_charge_algorithm": "APC Rate ($106.81). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 249.85, "10th_percentile": 249.85, "90th_percentile": 249.85 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 140.77, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 528.56, "10th_percentile": 528.56, "90th_percentile": 528.56 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 251.37, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 201.1, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 414.82, "standard_charge_algorithm": "Fee schedule rate ($414.82).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 360.87, "standard_charge_algorithm": "Case rate ($360.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 360.87, "standard_charge_algorithm": "Case rate ($360.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 360.87, "standard_charge_algorithm": "Case rate ($360.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 360.87, "standard_charge_algorithm": "Case rate ($360.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 360.87, "standard_charge_algorithm": "Case rate ($360.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 360.87, "standard_charge_algorithm": "Case rate ($360.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 213.6, "10th_percentile": 213.6, "90th_percentile": 213.6 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 55.3, "standard_charge_algorithm": "Fee schedule rate ($55.30).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 55.3, "standard_charge_algorithm": "Fee schedule rate ($55.30).", "count": "1 through 10", "median_amount": 57.46, "10th_percentile": 57.46, "90th_percentile": 57.46 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 101.15, "10th_percentile": 101.15, "90th_percentile": 101.15 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "13", "median_amount": 101.15, "10th_percentile": 101.15, "90th_percentile": 101.15 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 103.57, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "1 through 10", "median_amount": 104.18, "10th_percentile": 104.18, "90th_percentile": 104.18 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 55.3, "maximum": 414.82, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC MR Angio, Head - MR Head Angio WO IV Contrast", "code_information": [ { "code": "CASE-70544", "type": "LOCAL" }, { "code": "70544", "type": "CPT" }, { "code": "615", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 11278.06, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 634.66, "standard_charge_algorithm": "Fee schedule rate ($634.66).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4365.19, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7794.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6235.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 131.62, "standard_charge_algorithm": "Fee schedule rate ($131.62).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 131.62, "standard_charge_algorithm": "Fee schedule rate ($131.62).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3211.53, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 131.62, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC MR Angio, Neck W/Contrast - MR Neck Angio W IV Contrast", "code_information": [ { "code": "CASE-70548", "type": "LOCAL" }, { "code": "70548", "type": "CPT" }, { "code": "610", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 11278.06, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 5000.0, "standard_charge_algorithm": "Fee schedule rate ($5,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4365.19, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7794.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6235.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 1636.05, "standard_charge_algorithm": "Case rate ($1,636.05). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 145.38, "standard_charge_algorithm": "Fee schedule rate ($145.38).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 145.38, "standard_charge_algorithm": "Fee schedule rate ($145.38).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3211.53, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 145.38, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC MRI Brain - MRI Brain WO Contrast", "code_information": [ { "code": "CASE-70551", "type": "LOCAL" }, { "code": "70551", "type": "CPT" }, { "code": "611", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 8887.22, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 641.35, "standard_charge_algorithm": "Fee schedule rate ($641.35).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4365.19, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7794.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6235.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 1281.25, "standard_charge_algorithm": "Case rate ($1,281.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 1281.25, "standard_charge_algorithm": "Case rate ($1,281.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 1281.25, "standard_charge_algorithm": "Case rate ($1,281.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 1281.25, "standard_charge_algorithm": "Case rate ($1,281.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 1281.25, "standard_charge_algorithm": "Case rate ($1,281.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 1281.25, "standard_charge_algorithm": "Case rate ($1,281.25). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 105.19, "standard_charge_algorithm": "Fee schedule rate ($105.19).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 105.19, "standard_charge_algorithm": "Fee schedule rate ($105.19).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3211.53, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 105.19, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Radiologic Exam Chest Single View - Xr Chest 1 View", "code_information": [ { "code": "CASE-71045", "type": "LOCAL" }, { "code": "71045", "type": "CPT" }, { "code": "324", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5034.09, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 147.26, "10th_percentile": 147.26, "90th_percentile": 147.26 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "11", "median_amount": 149.39, "10th_percentile": 77.25, "90th_percentile": 149.39 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1532.0, "standard_charge_algorithm": "Case rate ($1,532). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3657.95, "standard_charge_algorithm": "APC Rate ($3,657.95). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3657.95, "standard_charge_algorithm": "APC Rate ($3,657.95). Final payment is multiplied by 229.17%.", "count": "17", "median_amount": 157.3, "10th_percentile": 65.07, "90th_percentile": 213.42 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 4820.93, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 117.25, "10th_percentile": 117.25, "90th_percentile": 117.25 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 8608.8, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 83.75, "10th_percentile": 83.75, "90th_percentile": 83.75 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6887.04, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 4153.58, "standard_charge_algorithm": "Case rate ($4,153.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 4776.68, "standard_charge_algorithm": "Case rate ($4,776.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 2861.26, "standard_charge_algorithm": "Case rate ($2,861.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 83.75, "10th_percentile": 83.75, "90th_percentile": 83.75 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 14.01, "standard_charge_algorithm": "Fee schedule rate ($14.01).", "count": "17", "median_amount": 77.25, "10th_percentile": 21.95, "90th_percentile": 231.75 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 14.01, "standard_charge_algorithm": "Fee schedule rate ($14.01).", "count": "16", "median_amount": 14.42, "10th_percentile": 14.01, "90th_percentile": 14.42 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 87.1, "10th_percentile": 82.74, "90th_percentile": 87.1 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "26", "median_amount": 83.75, "10th_percentile": 79.56, "90th_percentile": 83.75 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "75", "median_amount": 83.75, "10th_percentile": 83.75, "90th_percentile": 83.75 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3546.83, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3443.52, "standard_charge_algorithm": "APC Price ($3,443.52). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 14.01, "maximum": 8608.8, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Radiologic Exam Chest 2 Views - Xr Chest 2 Views", "code_information": [ { "code": "CASE-71046", "type": "LOCAL" }, { "code": "71046", "type": "CPT" }, { "code": "324", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 185.65, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "fee schedule", "standard_charge_dollar": 32.64, "standard_charge_algorithm": "Fee schedule rate ($32.64).", "count": "20", "median_amount": 47.73, "10th_percentile": 47.73, "90th_percentile": 95.46 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "fee schedule", "standard_charge_dollar": 32.64, "standard_charge_algorithm": "Fee schedule rate ($32.64).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "19", "median_amount": 149.39, "10th_percentile": 149.39, "90th_percentile": 448.17 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 34.67, "standard_charge_algorithm": "Fee schedule rate ($34.67).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 206.86, "10th_percentile": 33.91, "90th_percentile": 206.86 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "41", "median_amount": 206.86, "10th_percentile": 197.97, "90th_percentile": 213.42 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 108.88, "10th_percentile": 108.88, "90th_percentile": 108.88 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "16", "median_amount": 78.49, "10th_percentile": 78.29, "90th_percentile": 78.49 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 117.18, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "20", "median_amount": 117.25, "10th_percentile": 117.25, "90th_percentile": 117.25 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 53.36, "10th_percentile": 53.36, "90th_percentile": 53.36 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 209.25, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "1 through 10", "median_amount": 209.38, "10th_percentile": 209.38, "90th_percentile": 209.38 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "63", "median_amount": 83.75, "10th_percentile": 83.75, "90th_percentile": 83.75 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 167.4, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "1 through 10", "median_amount": 100.31, "10th_percentile": 100.31, "90th_percentile": 100.31 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "26", "median_amount": 83.75, "10th_percentile": 79.56, "90th_percentile": 83.75 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "standard_charge_algorithm": "Fee schedule rate ($18.87).", "count": "17", "median_amount": 77.25, "10th_percentile": 28.75, "90th_percentile": 143.75 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 18.87, "standard_charge_algorithm": "Fee schedule rate ($18.87).", "count": "23", "median_amount": 19.41, "10th_percentile": 18.87, "90th_percentile": 19.41 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "41", "median_amount": 87.1, "10th_percentile": 82.74, "90th_percentile": 87.1 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 83.75, "10th_percentile": 83.75, "90th_percentile": 83.75 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "190", "median_amount": 83.75, "10th_percentile": 83.75, "90th_percentile": 167.5 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "383", "median_amount": 83.75, "10th_percentile": 83.75, "90th_percentile": 83.75 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 87.1, "10th_percentile": 87.1, "90th_percentile": 87.1 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 86.21, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "1 through 10", "median_amount": 86.26, "10th_percentile": 86.26, "90th_percentile": 86.26 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 18.87, "maximum": 209.25, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC X-Ray Foot 3+ Vw - Xr Foot 3+ Views", "code_information": [ { "code": "CASE-73630", "type": "LOCAL" }, { "code": "73630", "type": "CPT" }, { "code": "320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 245.0, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "fee schedule", "standard_charge_dollar": 36.84, "standard_charge_algorithm": "Fee schedule rate ($36.84).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "fee schedule", "standard_charge_dollar": 36.84, "standard_charge_algorithm": "Fee schedule rate ($36.84).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 30.69, "standard_charge_algorithm": "Fee schedule rate ($30.69).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 39.14, "standard_charge_algorithm": "Fee schedule rate ($39.14).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 99.33, "10th_percentile": 99.33, "90th_percentile": 99.33 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 206.86, "10th_percentile": 206.86, "90th_percentile": 206.86 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 117.18, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 209.25, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 167.4, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 96.96, "standard_charge_algorithm": "Case rate ($96.96). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "standard_charge_algorithm": "Fee schedule rate ($21.02).", "count": "1 through 10", "median_amount": 77.25, "10th_percentile": 77.25, "90th_percentile": 77.25 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 21.02, "standard_charge_algorithm": "Fee schedule rate ($21.02).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "28", "median_amount": 83.75, "10th_percentile": 83.75, "90th_percentile": 83.75 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 86.21, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 21.02, "maximum": 209.25, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC CT Abd & Pelvis W/O Contrast - CT Abdomen Pelvis WO Contrast", "code_information": [ { "code": "CASE-74176", "type": "LOCAL" }, { "code": "74176", "type": "CPT" }, { "code": "352", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1191.34, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "fee schedule", "standard_charge_dollar": 148.83, "standard_charge_algorithm": "Case rate ($148.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "fee schedule", "standard_charge_dollar": 148.83, "standard_charge_algorithm": "Case rate ($148.83). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 158.13, "standard_charge_algorithm": "Fee schedule rate ($158.13).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 243.77, "standard_charge_algorithm": "APC Rate ($243.77). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 243.77, "standard_charge_algorithm": "APC Rate ($243.77). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 543.52, "10th_percentile": 543.52, "90th_percentile": 543.52 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 321.27, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 756.21, "10th_percentile": 756.21, "90th_percentile": 756.21 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 573.7, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 458.96, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 934.53, "standard_charge_algorithm": "Case rate ($934.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 934.53, "standard_charge_algorithm": "Case rate ($934.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 934.53, "standard_charge_algorithm": "Case rate ($934.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 934.53, "standard_charge_algorithm": "Case rate ($934.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 934.53, "standard_charge_algorithm": "Case rate ($934.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 934.53, "standard_charge_algorithm": "Case rate ($934.53). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 229.93, "10th_percentile": 229.93, "90th_percentile": 229.93 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 84.69, "standard_charge_algorithm": "Fee schedule rate ($84.69).", "count": "1 through 10", "median_amount": 212.09, "10th_percentile": 212.09, "90th_percentile": 212.09 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 84.69, "standard_charge_algorithm": "Fee schedule rate ($84.69).", "count": "1 through 10", "median_amount": 88.54, "10th_percentile": 88.54, "90th_percentile": 88.54 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 229.93, "10th_percentile": 229.93, "90th_percentile": 229.93 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 229.93, "10th_percentile": 229.93, "90th_percentile": 229.93 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 229.93, "10th_percentile": 214.54, "90th_percentile": 229.93 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 236.36, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 84.69, "maximum": 934.53, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Contrast Exam Thoracic Aorta - Aortagram Thoracic", "code_information": [ { "code": "CASE-75605", "type": "LOCAL" }, { "code": "75605", "type": "CPT" }, { "code": "320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 11372.49, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 5000.0, "standard_charge_algorithm": "Fee schedule rate ($5,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4365.19, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7794.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6235.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 54.73, "standard_charge_algorithm": "Fee schedule rate ($54.73).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 54.73, "standard_charge_algorithm": "Fee schedule rate ($54.73).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3211.53, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 54.73, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Contrast Exam Abdominl Aorta - IR Aortagram Abdomnl Serialogram", "code_information": [ { "code": "CASE-75625", "type": "LOCAL" }, { "code": "75625", "type": "CPT" }, { "code": "323", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6979.9, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 720.29, "standard_charge_algorithm": "Fee schedule rate ($720.29).", "count": "1 through 10", "median_amount": 6615.0, "10th_percentile": 6615.0, "90th_percentile": 6615.0 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 3947.73, "standard_charge_algorithm": "Fee schedule rate ($3,947.73).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 47.47, "standard_charge_algorithm": "Fee schedule rate ($47.47).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 47.47, "standard_charge_algorithm": "Fee schedule rate ($47.47).", "count": "1 through 10", "median_amount": 49.96, "10th_percentile": 49.96, "90th_percentile": 49.96 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 47.47, "maximum": 29605.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC X-Ray Aorta Leg Arteries - Abdom Aorta & Bi Iliofemoral Lower Extremity", "code_information": [ { "code": "CASE-75630", "type": "LOCAL" }, { "code": "75630", "type": "CPT" }, { "code": "320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 3824.68, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 751.26, "standard_charge_algorithm": "Fee schedule rate ($751.26).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 51.49, "standard_charge_algorithm": "Fee schedule rate ($51.49).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 51.49, "standard_charge_algorithm": "Fee schedule rate ($51.49).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 51.49, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Angio Extremity Unilat", "code_information": [ { "code": "CASE-75710", "type": "LOCAL" }, { "code": "75710", "type": "CPT" }, { "code": "320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 11349.28, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "fee schedule", "standard_charge_dollar": 96.55, "standard_charge_algorithm": "Fee schedule rate ($96.55).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "fee schedule", "standard_charge_dollar": 96.55, "standard_charge_algorithm": "Fee schedule rate ($96.55).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 720.29, "standard_charge_algorithm": "Fee schedule rate ($720.29).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 102.58, "standard_charge_algorithm": "Fee schedule rate ($102.58).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 54.46, "standard_charge_algorithm": "Fee schedule rate ($54.46).", "count": "1 through 10", "median_amount": 3225.76, "10th_percentile": 3225.76, "90th_percentile": 3225.76 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 54.46, "standard_charge_algorithm": "Fee schedule rate ($54.46).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 54.46, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Angio Extermity Bilat - Angiogram Extremity Bilateral", "code_information": [ { "code": "CASE-75716", "type": "LOCAL" }, { "code": "75716", "type": "CPT" }, { "code": "320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7016.13, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 4227.8, "10th_percentile": 4227.8, "90th_percentile": 4227.8 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 720.29, "standard_charge_algorithm": "Fee schedule rate ($720.29).", "count": "1 through 10", "median_amount": 720.29, "10th_percentile": 720.29, "90th_percentile": 720.29 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3225.87, "standard_charge_algorithm": "APC Rate ($3,225.87). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 7394.95, "10th_percentile": 7394.95, "90th_percentile": 7394.95 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 4251.48, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 4191.54, "10th_percentile": 4191.54, "90th_percentile": 4191.54 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7591.92, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6073.54, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 3932.28, "standard_charge_algorithm": "Fee schedule rate ($3,932.28).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 57.7, "standard_charge_algorithm": "Fee schedule rate ($57.70).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 57.7, "standard_charge_algorithm": "Fee schedule rate ($57.70).", "count": "1 through 10", "median_amount": 59.93, "10th_percentile": 59.93, "90th_percentile": 59.93 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 3113.72, "10th_percentile": 3113.72, "90th_percentile": 3113.72 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "15", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "35", "median_amount": 2993.96, "10th_percentile": 2790.83, "90th_percentile": 2993.96 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3127.87, "standard_charge_algorithm": "APC Price ($3,036.77). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3036.77, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 57.7, "maximum": 29605.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Angio Visceral Selectv/Supraselec", "code_information": [ { "code": "CASE-75726", "type": "LOCAL" }, { "code": "75726", "type": "CPT" }, { "code": "320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 21841.77, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 720.29, "standard_charge_algorithm": "Fee schedule rate ($720.29).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7492.46, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13379.39, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10703.51, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 3978.64, "standard_charge_algorithm": "Fee schedule rate ($3,978.64).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 62.56, "standard_charge_algorithm": "Fee schedule rate ($62.56).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 62.56, "standard_charge_algorithm": "Fee schedule rate ($62.56).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2571.01, "10th_percentile": 2405.75, "90th_percentile": 5142.01 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5512.31, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 62.56, "maximum": 29605.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Angio Pelvis - Angio Pelvic Selective or Supraselective", "code_information": [ { "code": "CASE-75736", "type": "LOCAL" }, { "code": "75736", "type": "CPT" }, { "code": "320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7178.5, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 720.29, "standard_charge_algorithm": "Fee schedule rate ($720.29).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5685.01, "standard_charge_algorithm": "APC Rate ($5,685.01). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7492.46, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13379.39, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10703.51, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 334.01, "standard_charge_algorithm": "Case rate ($334.01). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 75.49, "standard_charge_algorithm": "Fee schedule rate ($75.49).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 75.49, "standard_charge_algorithm": "Fee schedule rate ($75.49).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5512.31, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5351.75, "standard_charge_algorithm": "APC Price ($5,351.75). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 75.49, "maximum": 29605.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Venogram Extrem Unilat - Venogram Lower Extremity", "code_information": [ { "code": "CASE-75820", "type": "LOCAL" }, { "code": "75820", "type": "CPT" }, { "code": "320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 8007.04, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 54.4, "standard_charge_algorithm": "Fee schedule rate ($54.40).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 3417.0, "standard_charge_algorithm": "Case rate ($3,417). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 46.93, "standard_charge_algorithm": "Fee schedule rate ($46.93).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 46.93, "standard_charge_algorithm": "Fee schedule rate ($46.93).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 1477.66, "10th_percentile": 1477.66, "90th_percentile": 1477.66 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 46.93, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Venogram Infer Vena Cava - Veno Caval Inferior W Serialography Rs&I", "code_information": [ { "code": "CASE-75825", "type": "LOCAL" }, { "code": "75825", "type": "CPT" }, { "code": "320", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 8429.85, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 720.29, "standard_charge_algorithm": "Fee schedule rate ($720.29).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 3417.0, "standard_charge_algorithm": "Case rate ($3,417). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 49.36, "standard_charge_algorithm": "Fee schedule rate ($49.36).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 49.36, "standard_charge_algorithm": "Fee schedule rate ($49.36).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2993.96, "10th_percentile": 2993.96, "90th_percentile": 2993.96 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 49.36, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Venogram Super Vena Cava - IR Veno Caval Superior W Serialography", "code_information": [ { "code": "CASE-75827", "type": "LOCAL" }, { "code": "75827", "type": "CPT" }, { "code": "323", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7243.47, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 720.29, "standard_charge_algorithm": "Fee schedule rate ($720.29).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 3417.0, "standard_charge_algorithm": "Case rate ($3,417). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34808.26, "standard_charge_algorithm": "Case rate ($34,808.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 40030.08, "standard_charge_algorithm": "Case rate ($40,030.08). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23978.24, "standard_charge_algorithm": "Case rate ($23,978.24). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 18896.91, "standard_charge_algorithm": "Case rate ($18,896.91). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 52.33, "standard_charge_algorithm": "Fee schedule rate ($52.33).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 52.33, "standard_charge_algorithm": "Fee schedule rate ($52.33).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 52.33, "maximum": 40030.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC US Abdl Aorta Screen Aaa - US Abdomen Aortic Aneurysm Screening", "code_information": [ { "code": "CASE-76706", "type": "LOCAL" }, { "code": "76706", "type": "CPT" }, { "code": "402", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 392.28, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "fee schedule", "standard_charge_dollar": 113.39, "standard_charge_algorithm": "Case rate ($113.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.", "count": "1 through 10", "median_amount": 152.35, "10th_percentile": 105.2, "90th_percentile": 152.35 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "fee schedule", "standard_charge_dollar": 113.39, "standard_charge_algorithm": "Case rate ($113.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 301.7, "10th_percentile": 301.7, "90th_percentile": 301.7 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 120.48, "standard_charge_algorithm": "Fee schedule rate ($120.48).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 106.81, "standard_charge_algorithm": "APC Rate ($106.81). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 249.85, "10th_percentile": 249.85, "90th_percentile": 249.85 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 106.81, "standard_charge_algorithm": "APC Rate ($106.81). Final payment is multiplied by 229.17%.", "count": "15", "median_amount": 249.85, "10th_percentile": 239.12, "90th_percentile": 249.85 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 131.5, "10th_percentile": 125.14, "90th_percentile": 131.5 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 140.77, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 141.61, "10th_percentile": 141.61, "90th_percentile": 141.61 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 251.37, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 101.15, "10th_percentile": 101.15, "90th_percentile": 101.15 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 201.1, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 101.15, "10th_percentile": 96.26, "90th_percentile": 101.15 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 65.55, "standard_charge_algorithm": "Fee schedule rate ($65.55).", "count": "1 through 10", "median_amount": 270.07, "10th_percentile": 93.3, "90th_percentile": 270.07 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 65.55, "standard_charge_algorithm": "Fee schedule rate ($65.55).", "count": "1 through 10", "median_amount": 67.46, "10th_percentile": 65.55, "90th_percentile": 87.66 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 105.2, "10th_percentile": 105.2, "90th_percentile": 105.2 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "39", "median_amount": 101.15, "10th_percentile": 96.26, "90th_percentile": 101.15 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "139", "median_amount": 101.15, "10th_percentile": 101.15, "90th_percentile": 101.15 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 105.2, "10th_percentile": 105.2, "90th_percentile": 105.2 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 103.57, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 65.55, "maximum": 341.38, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC US, Retroperitnl Abd, Ltd - US Retroperitoneum Limited", "code_information": [ { "code": "CASE-76775", "type": "LOCAL" }, { "code": "76775", "type": "CPT" }, { "code": "402", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 507.93, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "fee schedule", "standard_charge_dollar": 45.71, "standard_charge_algorithm": "Case rate ($45.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "fee schedule", "standard_charge_dollar": 45.71, "standard_charge_algorithm": "Case rate ($45.71). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 81.74, "standard_charge_algorithm": "Fee schedule rate ($81.74).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 48.56, "standard_charge_algorithm": "Fee schedule rate ($48.56).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 243.77, "standard_charge_algorithm": "APC Rate ($243.77). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 243.77, "standard_charge_algorithm": "APC Rate ($243.77). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 240.36, "10th_percentile": 240.36, "90th_percentile": 240.36 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 321.27, "standard_charge_algorithm": "APC Price ($229.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 121.23, "10th_percentile": 121.23, "90th_percentile": 121.23 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 573.7, "standard_charge_algorithm": "APC Price ($229.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 458.96, "standard_charge_algorithm": "APC Price ($229.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 341.38, "standard_charge_algorithm": "Case rate ($341.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 26.96, "standard_charge_algorithm": "Fee schedule rate ($26.96).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 26.96, "standard_charge_algorithm": "Fee schedule rate ($26.96).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 101.15, "10th_percentile": 96.26, "90th_percentile": 101.15 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 101.15, "10th_percentile": 101.15, "90th_percentile": 101.15 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "APC Price ($229.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 236.36, "standard_charge_algorithm": "APC Price ($229.48). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 229.48, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 26.96, "maximum": 573.7, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC US Guide, Vascular Access", "code_information": [ { "code": "CASE-76937", "type": "LOCAL" }, { "code": "76937", "type": "CPT" }, { "code": "402", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6025.62, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 205.03, "10th_percentile": 205.03, "90th_percentile": 13780.28 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 5000.0, "standard_charge_algorithm": "Fee schedule rate ($5,000).", "count": "64", "median_amount": 208.01, "10th_percentile": 89.07, "90th_percentile": 208.01 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 137.4, "10th_percentile": 132.78, "90th_percentile": 137.4 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "30", "median_amount": 177.02, "10th_percentile": 96.86, "90th_percentile": 297.15 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4365.19, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7794.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6235.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 104.98, "standard_charge_algorithm": "Case rate ($104.98). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 104.98, "standard_charge_algorithm": "Case rate ($104.98). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 104.98, "standard_charge_algorithm": "Case rate ($104.98). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 104.98, "standard_charge_algorithm": "Case rate ($104.98). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 104.98, "standard_charge_algorithm": "Case rate ($104.98). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 104.98, "standard_charge_algorithm": "Case rate ($104.98). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2919.38, "standard_charge_algorithm": "Case rate ($2,919.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2919.38, "standard_charge_algorithm": "Case rate ($2,919.38). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "1 through 10", "median_amount": 297.15, "10th_percentile": 297.15, "90th_percentile": 297.15 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 9578.35, "10th_percentile": 9578.35, "90th_percentile": 9578.35 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3211.53, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 104.98, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Tumor Imaging (3d) - NM Tumor Localization Spect", "code_information": [ { "code": "CASE-78803", "type": "LOCAL" }, { "code": "78803", "type": "CPT" }, { "code": "341", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1297.4, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "fee schedule", "standard_charge_dollar": 417.12, "standard_charge_algorithm": "Fee schedule rate ($417.12).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "fee schedule", "standard_charge_dollar": 417.12, "standard_charge_algorithm": "Fee schedule rate ($417.12).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 374.66, "standard_charge_algorithm": "Fee schedule rate ($374.66).", "count": "1 through 10", "median_amount": 374.66, "10th_percentile": 374.66, "90th_percentile": 374.66 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 443.19, "standard_charge_algorithm": "Fee schedule rate ($443.19).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 554.73, "standard_charge_algorithm": "APC Rate ($554.73). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 554.73, "standard_charge_algorithm": "APC Rate ($554.73). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 3067.18, "10th_percentile": 1187.45, "90th_percentile": 3067.18 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 522.21, "standard_charge_algorithm": "APC Price ($522.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 731.1, "standard_charge_algorithm": "APC Price ($522.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 1738.52, "10th_percentile": 1738.52, "90th_percentile": 1738.52 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1305.53, "standard_charge_algorithm": "APC Price ($522.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 522.21, "standard_charge_algorithm": "APC Price ($522.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1044.42, "standard_charge_algorithm": "APC Price ($522.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 2010.33, "standard_charge_algorithm": "Case rate ($2,010.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 2010.33, "standard_charge_algorithm": "Case rate ($2,010.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 2010.33, "standard_charge_algorithm": "Case rate ($2,010.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2010.33, "standard_charge_algorithm": "Case rate ($2,010.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2010.33, "standard_charge_algorithm": "Case rate ($2,010.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2010.33, "standard_charge_algorithm": "Case rate ($2,010.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 522.21, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 488.95, "standard_charge_algorithm": "Fee schedule rate ($488.95).", "count": "1 through 10", "median_amount": 1145.44, "10th_percentile": 1145.44, "90th_percentile": 1145.44 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 488.95, "standard_charge_algorithm": "Fee schedule rate ($488.95).", "count": "1 through 10", "median_amount": 1162.55, "10th_percentile": 1162.55, "90th_percentile": 1162.55 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 522.21, "standard_charge_algorithm": "APC Price ($522.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 522.21, "standard_charge_algorithm": "APC Price ($522.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 522.21, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 1243.26, "10th_percentile": 1241.8, "90th_percentile": 1243.26 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 522.21, "standard_charge_algorithm": "APC Price ($522.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 1241.8, "10th_percentile": 1241.8, "90th_percentile": 1243.26 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 522.21, "standard_charge_algorithm": "APC Price ($522.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 537.88, "standard_charge_algorithm": "APC Price ($522.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 522.21, "standard_charge_algorithm": "APC Price ($522.21). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 374.66, "maximum": 2010.33, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Basic Metabolic Panel Calcium Ionized - Bundled Charge", "code_information": [ { "code": "CASE-80047", "type": "LOCAL" }, { "code": "80047", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5854.69, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 5000.0, "standard_charge_algorithm": "Fee schedule rate ($5,000).", "count": "1 through 10", "median_amount": 12.99, "10th_percentile": 12.99, "90th_percentile": 12.99 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4365.19, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7794.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6235.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 12.21, "standard_charge_algorithm": "Fee schedule rate ($12.21).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 12.21, "standard_charge_algorithm": "Fee schedule rate ($12.21).", "count": "1 through 10", "median_amount": 12.21, "10th_percentile": 12.21, "90th_percentile": 12.21 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3211.53, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 12.21, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Basic Metabolic Panel Calcium Total", "code_information": [ { "code": "CASE-80048", "type": "LOCAL" }, { "code": "80048", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5826.57, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "96", "median_amount": 56.58, "10th_percentile": 56.58, "90th_percentile": 82.8 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 5000.0, "standard_charge_algorithm": "Fee schedule rate ($5,000).", "count": "108", "median_amount": 32.11, "10th_percentile": 22.55, "90th_percentile": 57.4 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 52.17, "10th_percentile": 36.64, "90th_percentile": 52.95 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "124", "median_amount": 31.15, "10th_percentile": 8.46, "90th_percentile": 82.0 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 11.0, "10th_percentile": 11.0, "90th_percentile": 11.0 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 4365.19, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "18", "median_amount": 11.84, "10th_percentile": 11.84, "90th_percentile": 11.84 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 7794.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "1 through 10", "median_amount": 21.15, "10th_percentile": 21.15, "90th_percentile": 21.15 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 8.46, "10th_percentile": 8.46, "90th_percentile": 8.46 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6235.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 54.98, "standard_charge_algorithm": "Fee schedule rate ($54.98).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "32", "median_amount": 8.46, "10th_percentile": 8.46, "90th_percentile": 8.46 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7.53, "standard_charge_algorithm": "Fee schedule rate ($7.53).", "count": "60", "median_amount": 7.53, "10th_percentile": 7.53, "90th_percentile": 37.65 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7.53, "standard_charge_algorithm": "Fee schedule rate ($7.53).", "count": "137", "median_amount": 7.53, "10th_percentile": 7.53, "90th_percentile": 7.53 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "18", "median_amount": 8.8, "10th_percentile": 8.8, "90th_percentile": 8.8 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "157", "median_amount": 8.46, "10th_percentile": 8.46, "90th_percentile": 8.46 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "311", "median_amount": 8.46, "10th_percentile": 8.46, "90th_percentile": 8.46 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 8.8, "10th_percentile": 8.8, "90th_percentile": 8.8 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3211.53, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 7.53, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Metabolic Panel,Comprehensive", "code_information": [ { "code": "CASE-80053", "type": "LOCAL" }, { "code": "80053", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 193.94, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "79", "median_amount": 141.72, "10th_percentile": 141.72, "90th_percentile": 141.72 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "78", "median_amount": 143.77, "10th_percentile": 143.77, "90th_percentile": 143.77 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "standard_charge_algorithm": "Fee schedule rate ($10.56).", "count": "1 through 10", "median_amount": 10.56, "10th_percentile": 10.56, "90th_percentile": 32.63 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "standard_charge_algorithm": "Fee schedule rate ($10.56).", "count": "105", "median_amount": 10.56, "10th_percentile": 10.56, "90th_percentile": 10.56 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 13.73, "10th_percentile": 13.73, "90th_percentile": 13.73 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 10.56 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 14.78 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "1 through 10", "median_amount": 11.62, "10th_percentile": 11.62, "90th_percentile": 11.62 }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 26.4 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 10.56 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 21.12 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 88.63, "standard_charge_algorithm": "Fee schedule rate ($88.63).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 49.79, "10th_percentile": 49.79, "90th_percentile": 49.79 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 13.39 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.56 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 9.39, "standard_charge_algorithm": "Fee schedule rate ($9.39).", "count": "21", "median_amount": 9.39, "10th_percentile": 9.39, "90th_percentile": 9.39 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 9.39, "standard_charge_algorithm": "Fee schedule rate ($9.39).", "count": "50", "median_amount": 9.39, "10th_percentile": 9.39, "90th_percentile": 9.39 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.98, "standard_charge_algorithm": "Fee schedule rate ($10.98).", "count": "31", "median_amount": 10.98, "10th_percentile": 10.98, "90th_percentile": 10.98 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.56 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "standard_charge_algorithm": "Fee schedule rate ($10.56).", "count": "242", "median_amount": 10.56, "10th_percentile": 10.56, "90th_percentile": 10.56 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "standard_charge_algorithm": "Fee schedule rate ($10.56).", "count": "674", "median_amount": 10.56, "10th_percentile": 10.56, "90th_percentile": 10.56 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.56 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.88 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.56, "standard_charge_algorithm": "Fee schedule rate ($10.56).", "count": "1 through 10", "median_amount": 10.56, "10th_percentile": 10.56, "90th_percentile": 10.56 } ], "minimum": 9.39, "maximum": 88.63, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Lipid Panel", "code_information": [ { "code": "CASE-80061", "type": "LOCAL" }, { "code": "80061", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 847.21, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "110", "median_amount": 35.19, "10th_percentile": 35.19, "90th_percentile": 35.19 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "126", "median_amount": 35.7, "10th_percentile": 15.87, "90th_percentile": 35.7 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "standard_charge_algorithm": "Fee schedule rate ($13.39).", "count": "19", "median_amount": 13.39, "10th_percentile": 13.39, "90th_percentile": 13.39 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "standard_charge_algorithm": "Fee schedule rate ($13.39).", "count": "414", "median_amount": 13.39, "10th_percentile": 13.39, "90th_percentile": 13.39 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "12", "median_amount": 17.41, "10th_percentile": 17.41, "90th_percentile": 17.41 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 13.39 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 18.75 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "1 through 10", "median_amount": 14.73, "10th_percentile": 14.73, "90th_percentile": 14.73 }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 33.48 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 13.39 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 26.78 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 29.79, "standard_charge_algorithm": "Fee schedule rate ($29.79).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 12.35, "10th_percentile": 12.35, "90th_percentile": 12.35 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 13.39 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.39 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 11.91, "standard_charge_algorithm": "Fee schedule rate ($11.91).", "count": "145", "median_amount": 11.91, "10th_percentile": 11.91, "90th_percentile": 47.64 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 11.91, "standard_charge_algorithm": "Fee schedule rate ($11.91).", "count": "127", "median_amount": 11.91, "10th_percentile": 11.91, "90th_percentile": 11.91 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.93, "standard_charge_algorithm": "Fee schedule rate ($13.93).", "count": "150", "median_amount": 13.93, "10th_percentile": 13.93, "90th_percentile": 13.93 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.39 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "standard_charge_algorithm": "Fee schedule rate ($13.39).", "count": "786", "median_amount": 13.39, "10th_percentile": 13.39, "90th_percentile": 13.39 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "standard_charge_algorithm": "Fee schedule rate ($13.39).", "count": "2244", "median_amount": 13.39, "10th_percentile": 13.39, "90th_percentile": 13.39 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.39 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.79 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "standard_charge_algorithm": "Fee schedule rate ($13.39).", "count": "1 through 10", "median_amount": 13.39, "10th_percentile": 13.39, "90th_percentile": 13.39 } ], "minimum": 11.91, "maximum": 47.87, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Hepatitis Panel,Acute - Bundled Charge", "code_information": [ { "code": "CASE-80074", "type": "LOCAL" }, { "code": "80074", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 403.76, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "standard_charge_algorithm": "Fee schedule rate ($47.63).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "standard_charge_algorithm": "Fee schedule rate ($47.63).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 47.63 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 66.68 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 119.08 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 47.63 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 95.26 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 47.63 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 47.87, "standard_charge_algorithm": "Case rate ($47.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 47.63 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 42.37, "standard_charge_algorithm": "Fee schedule rate ($42.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 42.37, "standard_charge_algorithm": "Fee schedule rate ($42.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 49.54, "standard_charge_algorithm": "Fee schedule rate ($49.54).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 47.63 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "standard_charge_algorithm": "Fee schedule rate ($47.63).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "standard_charge_algorithm": "Fee schedule rate ($47.63).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 47.63 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 49.06 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 47.63, "standard_charge_algorithm": "Fee schedule rate ($47.63).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 42.37, "maximum": 119.08, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Drug Screen Quantitative Digoxin Total - Digoxin", "code_information": [ { "code": "CASE-80162", "type": "LOCAL" }, { "code": "80162", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 439.64, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 91.25, "10th_percentile": 91.25, "90th_percentile": 91.25 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 18.59, "10th_percentile": 18.59, "90th_percentile": 18.59 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 59.84, "standard_charge_algorithm": "Fee schedule rate ($59.84).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 57.68, "standard_charge_algorithm": "Case rate ($57.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 13.28 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 57.68, "standard_charge_algorithm": "Case rate ($57.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 57.68, "standard_charge_algorithm": "Case rate ($57.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 57.68, "standard_charge_algorithm": "Case rate ($57.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 57.68, "standard_charge_algorithm": "Case rate ($57.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 57.68, "standard_charge_algorithm": "Case rate ($57.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 11.81, "standard_charge_algorithm": "Fee schedule rate ($11.81).", "count": "1 through 10", "median_amount": 11.81, "10th_percentile": 11.81, "90th_percentile": 11.81 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 11.81, "standard_charge_algorithm": "Fee schedule rate ($11.81).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 13.81, "10th_percentile": 13.81, "90th_percentile": 13.81 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 13.28, "10th_percentile": 13.28, "90th_percentile": 13.28 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 13.28, "10th_percentile": 13.28, "90th_percentile": 13.28 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 11.81, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Drug Test Rapid Drug Screen, Urine", "code_information": [ { "code": "CASE-80305", "type": "LOCAL" }, { "code": "80305", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4060.31, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2672.15, "standard_charge_algorithm": "APC Rate ($2,672.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2672.15, "standard_charge_algorithm": "APC Rate ($2,672.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3521.71, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6288.77, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5031.02, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2518.57, "standard_charge_algorithm": "APC Price ($2,518.57). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 11.21, "standard_charge_algorithm": "Fee schedule rate ($11.21).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 11.21, "standard_charge_algorithm": "Fee schedule rate ($11.21).", "count": "1 through 10", "median_amount": 78.21, "10th_percentile": 78.21, "90th_percentile": 78.21 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2590.97, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 11.21, "maximum": 6288.77, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Urinalysis, Auto, W/Scope - Bundled Charge", "code_information": [ { "code": "CASE-81001", "type": "LOCAL" }, { "code": "81001", "type": "CPT" }, { "code": "307", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 290.83, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 47.61, "10th_percentile": 47.61, "90th_percentile": 47.61 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 48.3, "10th_percentile": 48.3, "90th_percentile": 48.3 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "standard_charge_algorithm": "Fee schedule rate ($3.17).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "standard_charge_algorithm": "Fee schedule rate ($3.17).", "count": "1 through 10", "median_amount": 3.17, "10th_percentile": 3.17, "90th_percentile": 21.04 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 3.17 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 4.44 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 17.25, "10th_percentile": 17.25, "90th_percentile": 17.25 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 7.93 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 3.17 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 6.34 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "standard_charge_algorithm": "Fee schedule rate ($17.30).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 13.97, "standard_charge_algorithm": "Case rate ($13.97). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 3.17 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 13.97, "standard_charge_algorithm": "Case rate ($13.97). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 13.97, "standard_charge_algorithm": "Case rate ($13.97). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.97, "standard_charge_algorithm": "Case rate ($13.97). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 13.97, "standard_charge_algorithm": "Case rate ($13.97). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 13.97, "standard_charge_algorithm": "Case rate ($13.97). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.17 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.82, "standard_charge_algorithm": "Fee schedule rate ($2.82).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.82, "standard_charge_algorithm": "Fee schedule rate ($2.82).", "count": "1 through 10", "median_amount": 2.82, "10th_percentile": 2.82, "90th_percentile": 2.82 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.3, "standard_charge_algorithm": "Fee schedule rate ($3.30).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.17 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "standard_charge_algorithm": "Fee schedule rate ($3.17).", "count": "1 through 10", "median_amount": 3.17, "10th_percentile": 3.17, "90th_percentile": 3.17 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "standard_charge_algorithm": "Fee schedule rate ($3.17).", "count": "1 through 10", "median_amount": 3.17, "10th_percentile": 3.17, "90th_percentile": 3.17 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.17 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.27 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.17, "standard_charge_algorithm": "Fee schedule rate ($3.17).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 2.82, "maximum": 17.3, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Urinalysis, Auto, W/O Scope - Urinalysis Chem Only", "code_information": [ { "code": "CASE-81003", "type": "LOCAL" }, { "code": "81003", "type": "CPT" }, { "code": "307", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 276.61, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 217.31, "standard_charge_algorithm": "APC Rate ($217.31). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 3.5, "10th_percentile": 3.5, "90th_percentile": 3.5 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 217.31, "standard_charge_algorithm": "APC Rate ($217.31). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 204.57, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 3.17, "10th_percentile": 3.17, "90th_percentile": 3.17 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 286.4, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 5.5, "10th_percentile": 5.5, "90th_percentile": 5.5 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 511.43, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 204.57, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 409.14, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 15.86, "standard_charge_algorithm": "Fee schedule rate ($15.86).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 204.57, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.0, "standard_charge_algorithm": "Fee schedule rate ($2).", "count": "1 through 10", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.0, "standard_charge_algorithm": "Fee schedule rate ($2).", "count": "1 through 10", "median_amount": 2.0, "10th_percentile": 2.0, "90th_percentile": 2.0 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 204.57, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 204.57, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 204.57, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 204.57, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2.25, "10th_percentile": 2.25, "90th_percentile": 2.25 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 204.57, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 210.71, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 204.57, "standard_charge_algorithm": "APC Price ($204.57). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 2.0, "maximum": 511.43, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC F5 Coagulation Factor V Anal Leiden Variant - Factor V Leiden", "code_information": [ { "code": "CASE-81241", "type": "LOCAL" }, { "code": "81241", "type": "CPT" }, { "code": "300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 802.12, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 176.4, "10th_percentile": 176.4, "90th_percentile": 176.4 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "standard_charge_algorithm": "Fee schedule rate ($73.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "standard_charge_algorithm": "Fee schedule rate ($73.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 102.72 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 183.43 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 146.74 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 409.78, "standard_charge_algorithm": "Case rate ($409.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 409.78, "standard_charge_algorithm": "Case rate ($409.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 409.78, "standard_charge_algorithm": "Case rate ($409.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 409.78, "standard_charge_algorithm": "Case rate ($409.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 409.78, "standard_charge_algorithm": "Case rate ($409.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 409.78, "standard_charge_algorithm": "Case rate ($409.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 65.26, "standard_charge_algorithm": "Fee schedule rate ($65.26).", "count": "1 through 10", "median_amount": 65.26, "10th_percentile": 65.26, "90th_percentile": 65.26 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 65.26, "standard_charge_algorithm": "Fee schedule rate ($65.26).", "count": "1 through 10", "median_amount": 65.26, "10th_percentile": 65.26, "90th_percentile": 65.26 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 76.3, "standard_charge_algorithm": "Fee schedule rate ($76.30).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "standard_charge_algorithm": "Fee schedule rate ($73.37).", "count": "1 through 10", "median_amount": 73.37, "10th_percentile": 73.37, "90th_percentile": 73.37 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "standard_charge_algorithm": "Fee schedule rate ($73.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 75.57 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "standard_charge_algorithm": "Fee schedule rate ($73.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 65.26, "maximum": 409.78, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Assay of Vit D,Calcifediol W Fractions, if Performed - Vitamin D 25", "code_information": [ { "code": "CASE-82306", "type": "LOCAL" }, { "code": "82306", "type": "CPT" }, { "code": "300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 417.48, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 134.55, "10th_percentile": 134.55, "90th_percentile": 134.55 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 409.5, "10th_percentile": 136.5, "90th_percentile": 409.5 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "standard_charge_algorithm": "Fee schedule rate ($29.60).", "count": "1 through 10", "median_amount": 30.98, "10th_percentile": 29.6, "90th_percentile": 30.98 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "standard_charge_algorithm": "Fee schedule rate ($29.60).", "count": "1 through 10", "median_amount": 29.6, "10th_percentile": 29.6, "90th_percentile": 29.6 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 29.6 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 41.44 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 74.0 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 29.6 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 59.2 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 80.75, "standard_charge_algorithm": "Fee schedule rate ($80.75).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 29.6 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 29.6 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 26.33, "standard_charge_algorithm": "Fee schedule rate ($26.33).", "count": "1 through 10", "median_amount": 26.33, "10th_percentile": 26.33, "90th_percentile": 26.33 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 26.33, "standard_charge_algorithm": "Fee schedule rate ($26.33).", "count": "1 through 10", "median_amount": 26.33, "10th_percentile": 26.33, "90th_percentile": 26.33 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 30.78, "standard_charge_algorithm": "Fee schedule rate ($30.78).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 29.6 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "standard_charge_algorithm": "Fee schedule rate ($29.60).", "count": "26", "median_amount": 29.6, "10th_percentile": 29.6, "90th_percentile": 29.6 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "standard_charge_algorithm": "Fee schedule rate ($29.60).", "count": "55", "median_amount": 29.6, "10th_percentile": 29.6, "90th_percentile": 29.6 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 29.6 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 30.49 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 29.6, "standard_charge_algorithm": "Fee schedule rate ($29.60).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 26.33, "maximum": 134.15, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Assay of Creatinine - Creatinine Serum", "code_information": [ { "code": "CASE-82565", "type": "LOCAL" }, { "code": "82565", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 674.6, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 42.78, "10th_percentile": 42.78, "90th_percentile": 85.56 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "fee schedule", "standard_charge_dollar": 281.36, "standard_charge_algorithm": "Case rate ($281.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 999 procedures at 50%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "29", "median_amount": 43.4, "10th_percentile": 43.4, "90th_percentile": 43.4 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 179.2, "standard_charge_algorithm": "APC Rate ($179.20). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 38.15, "10th_percentile": 10.12, "90th_percentile": 38.39 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 179.2, "standard_charge_algorithm": "APC Rate ($179.20). Final payment is multiplied by 229.17%.", "count": "31", "median_amount": 29.77, "10th_percentile": 9.8, "90th_percentile": 39.31 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 6.66, "10th_percentile": 6.66, "90th_percentile": 6.66 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 168.7, "standard_charge_algorithm": "APC Price ($168.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 236.17, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 421.74, "standard_charge_algorithm": "APC Price ($168.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 168.7, "standard_charge_algorithm": "APC Price ($168.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 5.12, "10th_percentile": 5.12, "90th_percentile": 5.12 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 337.39, "standard_charge_algorithm": "APC Price ($168.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 12.74, "standard_charge_algorithm": "Fee schedule rate ($12.74).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 168.7, "standard_charge_algorithm": "APC Price ($168.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 5.12, "10th_percentile": 5.12, "90th_percentile": 5.12 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.55, "standard_charge_algorithm": "Fee schedule rate ($4.55).", "count": "1 through 10", "median_amount": 4.55, "10th_percentile": 4.55, "90th_percentile": 4.55 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.55, "standard_charge_algorithm": "Fee schedule rate ($4.55).", "count": "45", "median_amount": 4.55, "10th_percentile": 4.55, "90th_percentile": 4.55 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 168.7, "standard_charge_algorithm": "APC Price ($168.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 168.7, "standard_charge_algorithm": "APC Price ($168.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 168.7, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 5.12, "10th_percentile": 5.12, "90th_percentile": 5.12 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 168.7, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "14", "median_amount": 5.12, "10th_percentile": 5.12, "90th_percentile": 5.12 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 168.7, "standard_charge_algorithm": "APC Price ($168.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 173.76, "standard_charge_algorithm": "APC Price ($168.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 168.7, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 4.55, "maximum": 421.74, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Vitamin B-12 - Vitamin B12", "code_information": [ { "code": "CASE-82607", "type": "LOCAL" }, { "code": "82607", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 534.07, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "standard_charge_algorithm": "Fee schedule rate ($15.08).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "standard_charge_algorithm": "Fee schedule rate ($15.08).", "count": "1 through 10", "median_amount": 15.08, "10th_percentile": 15.08, "90th_percentile": 15.08 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 21.11 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 37.7 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 30.16 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "standard_charge_algorithm": "Fee schedule rate ($13.41).", "count": "1 through 10", "median_amount": 13.41, "10th_percentile": 13.41, "90th_percentile": 13.41 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 13.41, "standard_charge_algorithm": "Fee schedule rate ($13.41).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.68, "standard_charge_algorithm": "Fee schedule rate ($15.68).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "standard_charge_algorithm": "Fee schedule rate ($15.08).", "count": "1 through 10", "median_amount": 15.08, "10th_percentile": 15.08, "90th_percentile": 15.08 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "standard_charge_algorithm": "Fee schedule rate ($15.08).", "count": "19", "median_amount": 15.08, "10th_percentile": 15.08, "90th_percentile": 15.08 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.08 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.53 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.08, "standard_charge_algorithm": "Fee schedule rate ($15.08).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 13.41, "maximum": 72.09, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Assay of Ferritin - Ferritin", "code_information": [ { "code": "CASE-82728", "type": "LOCAL" }, { "code": "82728", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 461.23, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 91.08, "10th_percentile": 91.08, "90th_percentile": 91.08 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 92.4, "10th_percentile": 92.4, "90th_percentile": 92.4 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "standard_charge_algorithm": "Fee schedule rate ($13.63).", "count": "1 through 10", "median_amount": 13.63, "10th_percentile": 13.63, "90th_percentile": 13.63 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "standard_charge_algorithm": "Fee schedule rate ($13.63).", "count": "1 through 10", "median_amount": 13.63, "10th_percentile": 13.63, "90th_percentile": 35.06 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 13.63 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 19.08 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 34.08 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 13.63 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 27.26 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 62.73, "standard_charge_algorithm": "Fee schedule rate ($62.73).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 13.63 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.63 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 12.12, "standard_charge_algorithm": "Fee schedule rate ($12.12).", "count": "1 through 10", "median_amount": 12.12, "10th_percentile": 12.12, "90th_percentile": 12.12 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 12.12, "standard_charge_algorithm": "Fee schedule rate ($12.12).", "count": "1 through 10", "median_amount": 12.12, "10th_percentile": 12.12, "90th_percentile": 12.12 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 14.18, "standard_charge_algorithm": "Fee schedule rate ($14.18).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.63 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "standard_charge_algorithm": "Fee schedule rate ($13.63).", "count": "27", "median_amount": 13.63, "10th_percentile": 13.63, "90th_percentile": 13.63 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "standard_charge_algorithm": "Fee schedule rate ($13.63).", "count": "43", "median_amount": 13.63, "10th_percentile": 13.63, "90th_percentile": 13.63 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.63 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 14.04 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 13.63, "standard_charge_algorithm": "Fee schedule rate ($13.63).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 12.12, "maximum": 62.73, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Blood Folic Acid Serum - Folate", "code_information": [ { "code": "CASE-82746", "type": "LOCAL" }, { "code": "82746", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 585.83, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 14.7, "10th_percentile": 14.7, "90th_percentile": 14.7 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 117.18, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 209.25, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 167.4, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 13.08, "standard_charge_algorithm": "Fee schedule rate ($13.08).", "count": "1 through 10", "median_amount": 13.08, "10th_percentile": 13.08, "90th_percentile": 13.08 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 13.08, "standard_charge_algorithm": "Fee schedule rate ($13.08).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 14.7, "10th_percentile": 14.7, "90th_percentile": 14.7 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "17", "median_amount": 14.7, "10th_percentile": 14.7, "90th_percentile": 14.7 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 86.21, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 13.08, "maximum": 209.25, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Assay of Gammaglobulin Ige - Immunoglobulin Ige", "code_information": [ { "code": "CASE-82785", "type": "LOCAL" }, { "code": "82785", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 769.18, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "standard_charge_algorithm": "Fee schedule rate ($16.46).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "standard_charge_algorithm": "Fee schedule rate ($16.46).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 23.04 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 41.15 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 32.92 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 14.64, "standard_charge_algorithm": "Fee schedule rate ($14.64).", "count": "1 through 10", "median_amount": 14.64, "10th_percentile": 14.64, "90th_percentile": 14.64 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 14.64, "standard_charge_algorithm": "Fee schedule rate ($14.64).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.12, "standard_charge_algorithm": "Fee schedule rate ($17.12).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "standard_charge_algorithm": "Fee schedule rate ($16.46).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "standard_charge_algorithm": "Fee schedule rate ($16.46).", "count": "1 through 10", "median_amount": 16.46, "10th_percentile": 16.46, "90th_percentile": 16.46 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.46 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.95 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.46, "standard_charge_algorithm": "Fee schedule rate ($16.46).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 14.64, "maximum": 44.18, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Blood Gases: Ph, Po2 & Pco2 - POCT Arterial Blood Gas", "code_information": [ { "code": "CASE-82803", "type": "LOCAL" }, { "code": "82803", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4788.7, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 608.43, "standard_charge_algorithm": "APC Rate ($608.43). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 608.43, "standard_charge_algorithm": "APC Rate ($608.43). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 572.76, "standard_charge_algorithm": "APC Price ($572.76). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 801.87, "standard_charge_algorithm": "APC Price ($572.76). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1431.91, "standard_charge_algorithm": "APC Price ($572.76). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 572.76, "standard_charge_algorithm": "APC Price ($572.76). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1145.53, "standard_charge_algorithm": "APC Price ($572.76). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 29.56, "standard_charge_algorithm": "Fee schedule rate ($29.56).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 1503.3, "standard_charge_algorithm": "Case rate ($1,503.30). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2518.57, "standard_charge_algorithm": "APC Price ($2,518.57). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 1728.82, "standard_charge_algorithm": "Case rate ($1,728.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 1035.57, "standard_charge_algorithm": "Case rate ($1,035.57). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "percent of total billed charges", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "75% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "75% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "percent of total billed charges", "standard_charge_percentage": 75.0, "standard_charge_algorithm": "75% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 572.76, "standard_charge_algorithm": "APC Price ($572.76). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 23.19, "standard_charge_algorithm": "Fee schedule rate ($23.19).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 23.19, "standard_charge_algorithm": "Fee schedule rate ($23.19).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 572.76, "standard_charge_algorithm": "APC Price ($572.76). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 572.76, "standard_charge_algorithm": "APC Price ($572.76). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 572.76, "standard_charge_algorithm": "APC Price ($572.76). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 259.0, "10th_percentile": 259.0, "90th_percentile": 259.0 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 572.76, "standard_charge_algorithm": "APC Price ($572.76). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 589.95, "standard_charge_algorithm": "APC Price ($572.76). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 23.19, "maximum": 2518.57, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Assay Quantitative,Blood Glucose - Glucose Random", "code_information": [ { "code": "CASE-82947", "type": "LOCAL" }, { "code": "82947", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 217.95, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "standard_charge_algorithm": "Fee schedule rate ($3.93).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "standard_charge_algorithm": "Fee schedule rate ($3.93).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 3.93 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 5.5 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 9.83 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 3.93 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 7.86 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 3.93 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.93 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3.5, "standard_charge_algorithm": "Fee schedule rate ($3.50).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3.5, "standard_charge_algorithm": "Fee schedule rate ($3.50).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 4.09, "standard_charge_algorithm": "Fee schedule rate ($4.09).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.93 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "standard_charge_algorithm": "Fee schedule rate ($3.93).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "standard_charge_algorithm": "Fee schedule rate ($3.93).", "count": "1 through 10", "median_amount": 3.93, "10th_percentile": 3.93, "90th_percentile": 3.93 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.93 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 4.05 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.93, "standard_charge_algorithm": "Fee schedule rate ($3.93).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 3.5, "maximum": 23.09, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Glucose POC", "code_information": [ { "code": "CASE-82948", "type": "LOCAL" }, { "code": "82948", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 7464.63, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 5000.0, "standard_charge_algorithm": "Fee schedule rate ($5,000).", "count": "1 through 10", "median_amount": 9.26, "10th_percentile": 6.76, "90th_percentile": 12.49 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 18.89, "10th_percentile": 13.73, "90th_percentile": 18.89 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "13", "median_amount": 11.92, "10th_percentile": 7.24, "90th_percentile": 29.69 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 6.55, "10th_percentile": 6.55, "90th_percentile": 6.55 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 4365.19, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 7.06, "10th_percentile": 7.06, "90th_percentile": 7.06 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7794.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6235.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 18.03, "standard_charge_algorithm": "Fee schedule rate ($18.03).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 9.85, "standard_charge_algorithm": "Case rate ($9.85). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "standard_charge_algorithm": "Fee schedule rate ($4.48).", "count": "1 through 10", "median_amount": 4.48, "10th_percentile": 4.48, "90th_percentile": 8.96 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.48, "standard_charge_algorithm": "Fee schedule rate ($4.48).", "count": "30", "median_amount": 4.48, "10th_percentile": 4.48, "90th_percentile": 29.69 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 29.69, "10th_percentile": 5.04, "90th_percentile": 29.69 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 5.04, "10th_percentile": 5.04, "90th_percentile": 5.04 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3211.53, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 4.48, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Glycosylated Hemoglobin Test - Hemoglobin A1c", "code_information": [ { "code": "CASE-83036", "type": "LOCAL" }, { "code": "83036", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 287.8, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 69.0, "10th_percentile": 69.0, "90th_percentile": 69.0 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "34", "median_amount": 70.0, "10th_percentile": 38.86, "90th_percentile": 70.0 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 9.71, "10th_percentile": 9.71, "90th_percentile": 63.63 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "41", "median_amount": 9.71, "10th_percentile": 9.71, "90th_percentile": 13.39 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 12.62, "10th_percentile": 12.62, "90th_percentile": 12.62 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 79.43, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 13.59, "10th_percentile": 13.59, "90th_percentile": 13.59 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 141.84, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "1 through 10", "median_amount": 24.72, "10th_percentile": 24.72, "90th_percentile": 24.72 }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 113.47, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 30.28, "standard_charge_algorithm": "Fee schedule rate ($30.28).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "13", "median_amount": 9.71, "10th_percentile": 9.71, "90th_percentile": 9.71 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 8.64, "standard_charge_algorithm": "Fee schedule rate ($8.64).", "count": "15", "median_amount": 8.64, "10th_percentile": 8.64, "90th_percentile": 8.64 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 8.64, "standard_charge_algorithm": "Fee schedule rate ($8.64).", "count": "28", "median_amount": 8.64, "10th_percentile": 8.64, "90th_percentile": 100.0 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "74", "median_amount": 9.71, "10th_percentile": 9.71, "90th_percentile": 9.71 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "214", "median_amount": 9.71, "10th_percentile": 9.71, "90th_percentile": 9.71 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 10.1, "10th_percentile": 10.1, "90th_percentile": 10.1 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 58.44, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 8.64, "maximum": 141.84, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Iron Binding Test - Iron and Iron Binding Capacity", "code_information": [ { "code": "CASE-83550", "type": "LOCAL" }, { "code": "83550", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 461.23, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 57.27, "10th_percentile": 57.27, "90th_percentile": 57.27 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 58.1, "10th_percentile": 58.1, "90th_percentile": 58.1 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "standard_charge_algorithm": "Fee schedule rate ($8.74).", "count": "1 through 10", "median_amount": 8.74, "10th_percentile": 8.74, "90th_percentile": 8.74 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "standard_charge_algorithm": "Fee schedule rate ($8.74).", "count": "1 through 10", "median_amount": 8.74, "10th_percentile": 8.74, "90th_percentile": 8.74 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 8.74 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 12.24 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 21.85 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 8.74 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 17.48 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 55.52, "standard_charge_algorithm": "Fee schedule rate ($55.52).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 8.74 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 8.74 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "standard_charge_algorithm": "Fee schedule rate ($7.77).", "count": "1 through 10", "median_amount": 7.77, "10th_percentile": 7.77, "90th_percentile": 7.77 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7.77, "standard_charge_algorithm": "Fee schedule rate ($7.77).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 9.09, "standard_charge_algorithm": "Fee schedule rate ($9.09).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 8.74 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "standard_charge_algorithm": "Fee schedule rate ($8.74).", "count": "27", "median_amount": 8.74, "10th_percentile": 8.74, "90th_percentile": 8.74 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "standard_charge_algorithm": "Fee schedule rate ($8.74).", "count": "43", "median_amount": 8.74, "10th_percentile": 8.74, "90th_percentile": 8.74 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 8.74 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 9.0 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 8.74, "standard_charge_algorithm": "Fee schedule rate ($8.74).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 7.77, "maximum": 55.52, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Assay of Blood Lipoprotein,Ldl Cholest - Ldl Cholesterol Direct", "code_information": [ { "code": "CASE-83721", "type": "LOCAL" }, { "code": "83721", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 159.5, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 52.5, "10th_percentile": 52.5, "90th_percentile": 52.5 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 40.38, "standard_charge_algorithm": "Fee schedule rate ($40.38).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 10.5 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 9.34, "standard_charge_algorithm": "Fee schedule rate ($9.34).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 9.34, "standard_charge_algorithm": "Fee schedule rate ($9.34).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 10.5, "10th_percentile": 10.5, "90th_percentile": 10.5 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 10.5, "10th_percentile": 10.5, "90th_percentile": 10.5 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 9.34, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Assay of Magnesium - Magnesium", "code_information": [ { "code": "CASE-83735", "type": "LOCAL" }, { "code": "83735", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 251.2, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 55.2, "10th_percentile": 55.2, "90th_percentile": 55.2 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "14", "median_amount": 56.0, "10th_percentile": 56.0, "90th_percentile": 56.0 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 50.9, "10th_percentile": 35.93, "90th_percentile": 50.9 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "40", "median_amount": 6.7, "10th_percentile": 6.7, "90th_percentile": 38.07 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 8.71, "10th_percentile": 8.71, "90th_percentile": 8.71 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "11", "median_amount": 9.38, "10th_percentile": 9.38, "90th_percentile": 9.38 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 56.38, "standard_charge_algorithm": "Fee schedule rate ($56.38).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 127.96, "standard_charge_algorithm": "APC Price ($127.96). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 6.7, "10th_percentile": 6.7, "90th_percentile": 6.7 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5.96, "standard_charge_algorithm": "Fee schedule rate ($5.96).", "count": "15", "median_amount": 5.96, "10th_percentile": 5.96, "90th_percentile": 17.88 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5.96, "standard_charge_algorithm": "Fee schedule rate ($5.96).", "count": "17", "median_amount": 5.96, "10th_percentile": 5.96, "90th_percentile": 5.96 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "55", "median_amount": 6.7, "10th_percentile": 6.7, "90th_percentile": 6.7 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "116", "median_amount": 6.7, "10th_percentile": 6.7, "90th_percentile": 6.7 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 6.97, "10th_percentile": 6.97, "90th_percentile": 6.97 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 5.96, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Natriuretic Peptide - B-Type Natriuretic Peptide (Bnp)", "code_information": [ { "code": "CASE-83880", "type": "LOCAL" }, { "code": "83880", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 263.83, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 82.8, "10th_percentile": 56.58, "90th_percentile": 115.71 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "26", "median_amount": 84.0, "10th_percentile": 46.63, "90th_percentile": 117.39 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "38", "median_amount": 39.26, "10th_percentile": 38.32, "90th_percentile": 84.83 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 51.04, "10th_percentile": 51.04, "90th_percentile": 51.04 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "14", "median_amount": 54.96, "10th_percentile": 54.96, "90th_percentile": 54.96 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 30.0, "10th_percentile": 30.0, "90th_percentile": 30.0 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "1 through 10", "median_amount": 98.15, "10th_percentile": 98.15, "90th_percentile": 98.15 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 39.26, "10th_percentile": 39.26, "90th_percentile": 39.26 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "1 through 10", "median_amount": 29.66, "10th_percentile": 29.66, "90th_percentile": 29.66 }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 75.21, "standard_charge_algorithm": "Fee schedule rate ($75.21).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 39.26 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 134.15, "standard_charge_algorithm": "Case rate ($134.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "31", "median_amount": 39.26, "10th_percentile": 39.26, "90th_percentile": 39.26 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 34.92, "standard_charge_algorithm": "Fee schedule rate ($34.92).", "count": "20", "median_amount": 34.92, "10th_percentile": 34.92, "90th_percentile": 174.6 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 34.92, "standard_charge_algorithm": "Fee schedule rate ($34.92).", "count": "35", "median_amount": 34.92, "10th_percentile": 34.92, "90th_percentile": 34.92 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "143", "median_amount": 39.26, "10th_percentile": 39.26, "90th_percentile": 39.26 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "326", "median_amount": 39.26, "10th_percentile": 39.26, "90th_percentile": 39.26 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 40.83, "10th_percentile": 40.83, "90th_percentile": 40.83 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 34.92, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Assay of Serum Potassium - Potassium", "code_information": [ { "code": "CASE-84132", "type": "LOCAL" }, { "code": "84132", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 6890.63, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2672.15, "standard_charge_algorithm": "APC Rate ($2,672.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2672.15, "standard_charge_algorithm": "APC Rate ($2,672.15). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 18.29, "10th_percentile": 18.29, "90th_percentile": 18.29 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3521.71, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6288.77, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5031.02, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2518.57, "standard_charge_algorithm": "APC Price ($2,518.57). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($7,175) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.23, "standard_charge_algorithm": "Fee schedule rate ($4.23).", "count": "1 through 10", "median_amount": 8.46, "10th_percentile": 8.46, "90th_percentile": 8.46 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.23, "standard_charge_algorithm": "Fee schedule rate ($4.23).", "count": "1 through 10", "median_amount": 4.23, "10th_percentile": 4.23, "90th_percentile": 4.23 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 4.76, "10th_percentile": 4.76, "90th_percentile": 4.76 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2590.97, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 4.23, "maximum": 6288.77, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Prostate Specific Antigen,Total - Psa", "code_information": [ { "code": "CASE-84153", "type": "LOCAL" }, { "code": "84153", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 184.29, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 100.74, "10th_percentile": 100.74, "90th_percentile": 100.74 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 102.2, "10th_percentile": 102.2, "90th_percentile": 102.2 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "13", "median_amount": 18.39, "10th_percentile": 18.39, "90th_percentile": 18.39 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 23.91, "10th_percentile": 23.91, "90th_percentile": 23.91 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 36.5, "10th_percentile": 36.5, "90th_percentile": 36.5 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 51.19, "standard_charge_algorithm": "Fee schedule rate ($51.19).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 44.18, "standard_charge_algorithm": "Case rate ($44.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 18.39, "10th_percentile": 18.39, "90th_percentile": 18.39 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 16.36, "standard_charge_algorithm": "Fee schedule rate ($16.36).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 16.36, "standard_charge_algorithm": "Fee schedule rate ($16.36).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "25", "median_amount": 18.39, "10th_percentile": 18.39, "90th_percentile": 18.39 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "70", "median_amount": 18.39, "10th_percentile": 18.39, "90th_percentile": 18.39 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 16.36, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Protein Tot Xcpt Refractometry Serum - Protein Total", "code_information": [ { "code": "CASE-84155", "type": "LOCAL" }, { "code": "84155", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 334.85, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 33.12, "10th_percentile": 33.12, "90th_percentile": 33.12 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "standard_charge_algorithm": "Fee schedule rate ($3.67).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "standard_charge_algorithm": "Fee schedule rate ($3.67).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 5.14 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 9.18 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 7.34 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 40.38, "standard_charge_algorithm": "Fee schedule rate ($40.38).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3.26, "standard_charge_algorithm": "Fee schedule rate ($3.26).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3.26, "standard_charge_algorithm": "Fee schedule rate ($3.26).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.82, "standard_charge_algorithm": "Fee schedule rate ($3.82).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "standard_charge_algorithm": "Fee schedule rate ($3.67).", "count": "1 through 10", "median_amount": 3.67, "10th_percentile": 3.67, "90th_percentile": 3.67 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "standard_charge_algorithm": "Fee schedule rate ($3.67).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.67 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.78 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 3.67, "standard_charge_algorithm": "Fee schedule rate ($3.67).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 3.26, "maximum": 40.38, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Assay of Serum Sodium - Sodium", "code_information": [ { "code": "CASE-84295", "type": "LOCAL" }, { "code": "84295", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 10274.58, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 7000.0, "standard_charge_algorithm": "Fee schedule rate ($7,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 50964.65, "standard_charge_algorithm": "Case rate ($50,964.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 58610.21, "standard_charge_algorithm": "Case rate ($58,610.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 35107.84, "standard_charge_algorithm": "Case rate ($35,107.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "standard_charge_algorithm": "Fee schedule rate ($4.28).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.28, "standard_charge_algorithm": "Fee schedule rate ($4.28).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 4.28, "maximum": 58610.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Assay of Free Thyroxine - T4 Free", "code_information": [ { "code": "CASE-84439", "type": "LOCAL" }, { "code": "84439", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 376.98, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 13.8, "10th_percentile": 13.8, "90th_percentile": 13.8 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "12", "median_amount": 14.0, "10th_percentile": 14.0, "90th_percentile": 42.0 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 12.73, "10th_percentile": 9.02, "90th_percentile": 12.73 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "11", "median_amount": 9.02, "10th_percentile": 7.53, "90th_percentile": 9.02 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 9.02, "10th_percentile": 9.02, "90th_percentile": 9.02 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 12.63, "10th_percentile": 12.63, "90th_percentile": 12.63 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 48.54, "standard_charge_algorithm": "Fee schedule rate ($48.54).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 9.02 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 9.02, "10th_percentile": 9.02, "90th_percentile": 9.02 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 8.02, "standard_charge_algorithm": "Fee schedule rate ($8.02).", "count": "1 through 10", "median_amount": 8.02, "10th_percentile": 8.02, "90th_percentile": 8.02 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 8.02, "standard_charge_algorithm": "Fee schedule rate ($8.02).", "count": "1 through 10", "median_amount": 8.02, "10th_percentile": 8.02, "90th_percentile": 8.02 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "32", "median_amount": 9.02, "10th_percentile": 9.02, "90th_percentile": 9.02 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "70", "median_amount": 9.02, "10th_percentile": 9.02, "90th_percentile": 9.02 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 8.02, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Assay Thyroid Stim Hormone - Thyroid Stimulating Hormone", "code_information": [ { "code": "CASE-84443", "type": "LOCAL" }, { "code": "84443", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 290.54, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 106.26, "10th_percentile": 95.73, "90th_percentile": 106.26 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "50", "median_amount": 107.8, "10th_percentile": 59.85, "90th_percentile": 323.4 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "standard_charge_algorithm": "Fee schedule rate ($16.80).", "count": "1 through 10", "median_amount": 16.8, "10th_percentile": 16.8, "90th_percentile": 97.98 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "standard_charge_algorithm": "Fee schedule rate ($16.80).", "count": "62", "median_amount": 16.8, "10th_percentile": 16.8, "90th_percentile": 57.98 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 21.84, "10th_percentile": 21.84, "90th_percentile": 21.84 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 16.8 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 23.52 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 42.0 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 16.8 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 33.6 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 49.82, "standard_charge_algorithm": "Fee schedule rate ($49.82).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 95.7, "standard_charge_algorithm": "Case rate ($95.70). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 58.82, "10th_percentile": 58.82, "90th_percentile": 58.82 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 40.75 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 95.7, "standard_charge_algorithm": "Case rate ($95.70). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 95.7, "standard_charge_algorithm": "Case rate ($95.70). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 95.7, "standard_charge_algorithm": "Case rate ($95.70). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 95.7, "standard_charge_algorithm": "Case rate ($95.70). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 95.7, "standard_charge_algorithm": "Case rate ($95.70). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.8 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 14.94, "standard_charge_algorithm": "Fee schedule rate ($14.94).", "count": "11", "median_amount": 14.94, "10th_percentile": 14.94, "90th_percentile": 14.94 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 14.94, "standard_charge_algorithm": "Fee schedule rate ($14.94).", "count": "21", "median_amount": 14.94, "10th_percentile": 14.94, "90th_percentile": 14.94 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.47, "standard_charge_algorithm": "Fee schedule rate ($17.47).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.8 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "standard_charge_algorithm": "Fee schedule rate ($16.80).", "count": "77", "median_amount": 16.8, "10th_percentile": 16.8, "90th_percentile": 16.8 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "standard_charge_algorithm": "Fee schedule rate ($16.80).", "count": "238", "median_amount": 16.8, "10th_percentile": 16.8, "90th_percentile": 16.8 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.8 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.3 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 16.8, "standard_charge_algorithm": "Fee schedule rate ($16.80).", "count": "1 through 10", "median_amount": 16.8, "10th_percentile": 16.8, "90th_percentile": 16.8 } ], "minimum": 14.94, "maximum": 95.7, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Transferase Aspartate Amino (Ast) (Sgot) - Ast (Sgot)", "code_information": [ { "code": "CASE-84450", "type": "LOCAL" }, { "code": "84450", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 287.77, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 182.7, "10th_percentile": 60.9, "90th_percentile": 182.7 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 5.18, "10th_percentile": 5.18, "90th_percentile": 32.04 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 50.47, "standard_charge_algorithm": "Fee schedule rate ($50.47).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 112.76 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.61, "standard_charge_algorithm": "Fee schedule rate ($4.61).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.61, "standard_charge_algorithm": "Fee schedule rate ($4.61).", "count": "1 through 10", "median_amount": 4.61, "10th_percentile": 4.61, "90th_percentile": 4.61 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 5.18, "10th_percentile": 5.18, "90th_percentile": 5.18 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 4.61, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Transferase Alanine Amino (Alt) (Sgpt) - Alt (Sgpt)", "code_information": [ { "code": "CASE-84460", "type": "LOCAL" }, { "code": "84460", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 287.77, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 182.7, "10th_percentile": 60.9, "90th_percentile": 182.7 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 5.3, "10th_percentile": 5.3, "90th_percentile": 32.04 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 50.47, "standard_charge_algorithm": "Fee schedule rate ($50.47).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 112.76 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 23.09, "standard_charge_algorithm": "Case rate ($23.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.71, "standard_charge_algorithm": "Fee schedule rate ($4.71).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 4.71, "standard_charge_algorithm": "Fee schedule rate ($4.71).", "count": "1 through 10", "median_amount": 4.71, "10th_percentile": 4.71, "90th_percentile": 4.71 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 5.3, "10th_percentile": 5.3, "90th_percentile": 5.3 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 4.71, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Chorionic Gonadotropin, Quant - Hcg Quantitative Blood", "code_information": [ { "code": "CASE-84702", "type": "LOCAL" }, { "code": "84702", "type": "CPT" }, { "code": "301", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 211.21, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 51.69, "10th_percentile": 51.69, "90th_percentile": 51.69 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "standard_charge_algorithm": "Fee schedule rate ($15.05).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "standard_charge_algorithm": "Fee schedule rate ($15.05).", "count": "1 through 10", "median_amount": 142.38, "10th_percentile": 142.38, "90th_percentile": 142.38 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 15.05 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 21.07 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 37.63 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 15.05 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 30.1 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 15.05 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 72.09, "standard_charge_algorithm": "Case rate ($72.09). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.05 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "standard_charge_algorithm": "Fee schedule rate ($13.39).", "count": "1 through 10", "median_amount": 13.39, "10th_percentile": 13.39, "90th_percentile": 13.39 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 13.39, "standard_charge_algorithm": "Fee schedule rate ($13.39).", "count": "1 through 10", "median_amount": 13.39, "10th_percentile": 13.39, "90th_percentile": 13.39 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.65, "standard_charge_algorithm": "Fee schedule rate ($15.65).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.05 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "standard_charge_algorithm": "Fee schedule rate ($15.05).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "standard_charge_algorithm": "Fee schedule rate ($15.05).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.05 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.5 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 15.05, "standard_charge_algorithm": "Fee schedule rate ($15.05).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 13.39, "maximum": 72.09, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Hematocrit - Hematocrit", "code_information": [ { "code": "CASE-85014", "type": "LOCAL" }, { "code": "85014", "type": "CPT" }, { "code": "305", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 400.73, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "standard_charge_algorithm": "Fee schedule rate ($2.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "standard_charge_algorithm": "Fee schedule rate ($2.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 2.37 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 3.32 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 5.93 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 2.37 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 4.74 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 2.37 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2.37 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.11, "standard_charge_algorithm": "Fee schedule rate ($2.11).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.11, "standard_charge_algorithm": "Fee schedule rate ($2.11).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2.46, "standard_charge_algorithm": "Fee schedule rate ($2.46).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2.37 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "standard_charge_algorithm": "Fee schedule rate ($2.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "standard_charge_algorithm": "Fee schedule rate ($2.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2.37 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2.44 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2.37, "standard_charge_algorithm": "Fee schedule rate ($2.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 2.11, "maximum": 32.51, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Hemoglobin - Hemoglobin, Blood Gases", "code_information": [ { "code": "CASE-85018", "type": "LOCAL" }, { "code": "85018", "type": "CPT" }, { "code": "305", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5856.47, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 5000.0, "standard_charge_algorithm": "Fee schedule rate ($5,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4365.19, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7794.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6235.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.11, "standard_charge_algorithm": "Fee schedule rate ($2.11).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.11, "standard_charge_algorithm": "Fee schedule rate ($2.11).", "count": "1 through 10", "median_amount": 2.11, "10th_percentile": 2.11, "90th_percentile": 2.11 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 2.37, "10th_percentile": 2.37, "90th_percentile": 2.37 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3211.53, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 2.11, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Complete Cbc & Auto Diff Wbc - Additional Charge", "code_information": [ { "code": "CASE-85025", "type": "LOCAL" }, { "code": "85025", "type": "CPT" }, { "code": "305", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 214.91, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "62", "median_amount": 26.22, "10th_percentile": 26.22, "90th_percentile": 26.22 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "68", "median_amount": 26.6, "10th_percentile": 14.78, "90th_percentile": 26.6 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 7.77, "10th_percentile": 6.04, "90th_percentile": 24.18 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 88.91, "standard_charge_algorithm": "APC Rate ($88.91). Final payment is multiplied by 229.17%.", "count": "98", "median_amount": 7.77, "10th_percentile": 7.77, "90th_percentile": 15.42 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 10.1, "10th_percentile": 10.1, "90th_percentile": 10.1 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 7.77, "10th_percentile": 7.77, "90th_percentile": 7.77 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 117.18, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "11", "median_amount": 10.88, "10th_percentile": 10.88, "90th_percentile": 10.88 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 9.5, "10th_percentile": 9.5, "90th_percentile": 9.5 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 209.25, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "1 through 10", "median_amount": 19.43, "10th_percentile": 19.43, "90th_percentile": 19.43 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 7.77, "10th_percentile": 7.77, "90th_percentile": 7.77 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 167.4, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 25.75, "standard_charge_algorithm": "Fee schedule rate ($25.75).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "37", "median_amount": 7.77, "10th_percentile": 7.77, "90th_percentile": 7.77 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 6.91, "standard_charge_algorithm": "Fee schedule rate ($6.91).", "count": "41", "median_amount": 6.91, "10th_percentile": 6.91, "90th_percentile": 34.55 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 6.91, "standard_charge_algorithm": "Fee schedule rate ($6.91).", "count": "53", "median_amount": 6.91, "10th_percentile": 6.91, "90th_percentile": 6.91 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "28", "median_amount": 8.08, "10th_percentile": 8.08, "90th_percentile": 8.08 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "200", "median_amount": 7.77, "10th_percentile": 7.77, "90th_percentile": 7.77 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "545", "median_amount": 7.77, "10th_percentile": 7.77, "90th_percentile": 7.77 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 8.08, "10th_percentile": 8.08, "90th_percentile": 8.08 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 86.21, "standard_charge_algorithm": "APC Price ($83.70). The procedure can be bundled into a composite APC if other services qualifying for that composite APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 83.7, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 7.77, "10th_percentile": 7.77, "90th_percentile": 7.77 } ], "minimum": 6.91, "maximum": 209.25, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Complete Cbc - Cbc", "code_information": [ { "code": "CASE-85027", "type": "LOCAL" }, { "code": "85027", "type": "CPT" }, { "code": "305", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 5971.35, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "36", "median_amount": 26.22, "10th_percentile": 26.22, "90th_percentile": 26.22 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 5000.0, "standard_charge_algorithm": "Fee schedule rate ($5,000).", "count": "62", "median_amount": 12.22, "10th_percentile": 9.73, "90th_percentile": 26.6 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 14802.0, "standard_charge_algorithm": "Case rate ($14,802).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 24.18, "10th_percentile": 16.98, "90th_percentile": 24.54 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3312.15, "standard_charge_algorithm": "APC Rate ($3,312.15). Final payment is multiplied by 229.17%.", "count": "43", "median_amount": 25.99, "10th_percentile": 12.13, "90th_percentile": 38.0 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 8.41, "10th_percentile": 8.41, "90th_percentile": 8.41 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 4365.19, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 9.06, "10th_percentile": 9.06, "90th_percentile": 9.06 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7794.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6235.98, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 27.4, "standard_charge_algorithm": "Fee schedule rate ($27.40).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 32.51, "standard_charge_algorithm": "Case rate ($32.51). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 6.47, "10th_percentile": 6.47, "90th_percentile": 6.47 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "standard_charge_algorithm": "Fee schedule rate ($5.75).", "count": "29", "median_amount": 11.5, "10th_percentile": 5.75, "90th_percentile": 28.75 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5.75, "standard_charge_algorithm": "Fee schedule rate ($5.75).", "count": "96", "median_amount": 5.75, "10th_percentile": 5.75, "90th_percentile": 5.75 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 6.73, "10th_percentile": 6.73, "90th_percentile": 13.93 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 6.47, "10th_percentile": 6.47, "90th_percentile": 38.0 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 6.47, "10th_percentile": 6.47, "90th_percentile": 6.47 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3211.53, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3117.99, "standard_charge_algorithm": "APC Price ($3,117.99). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 5.75, "maximum": 14802.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Coagulation Time, Activated - Activated Clotting Time", "code_information": [ { "code": "CASE-85347", "type": "LOCAL" }, { "code": "85347", "type": "CPT" }, { "code": "305", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 20156.65, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 41.4, "10th_percentile": 41.4, "90th_percentile": 41.4 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 7000.0, "standard_charge_algorithm": "Fee schedule rate ($7,000).", "count": "16", "median_amount": 20.66, "10th_percentile": 10.71, "90th_percentile": 52.21 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 38.74, "10th_percentile": 38.74, "90th_percentile": 38.74 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "24", "median_amount": 39.96, "10th_percentile": 24.77, "90th_percentile": 60.0 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 5.56, "10th_percentile": 5.56, "90th_percentile": 5.56 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 15543.99, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 27757.13, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 22205.7, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 43.26, "standard_charge_algorithm": "Fee schedule rate ($43.26).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 50964.65, "standard_charge_algorithm": "Case rate ($50,964.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 58610.21, "standard_charge_algorithm": "Case rate ($58,610.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 35107.84, "standard_charge_algorithm": "Case rate ($35,107.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3.81, "standard_charge_algorithm": "Fee schedule rate ($3.81).", "count": "1 through 10", "median_amount": 11.43, "10th_percentile": 3.81, "90th_percentile": 11.43 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3.81, "standard_charge_algorithm": "Fee schedule rate ($3.81).", "count": "29", "median_amount": 3.81, "10th_percentile": 3.81, "90th_percentile": 60.0 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 4.28, "10th_percentile": 4.28, "90th_percentile": 4.28 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11435.94, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 3.81, "maximum": 58610.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Prothrombin Time", "code_information": [ { "code": "CASE-85610", "type": "LOCAL" }, { "code": "85610", "type": "CPT" }, { "code": "305", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 53.49, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "152", "median_amount": 11.73, "10th_percentile": 8.5, "90th_percentile": 11.73 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "88", "median_amount": 11.9, "10th_percentile": 11.9, "90th_percentile": 11.9 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 2.7, "10th_percentile": 2.7, "90th_percentile": 2.7 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "385", "median_amount": 17.0, "10th_percentile": 4.29, "90th_percentile": 17.0 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "28", "median_amount": 152.83, "10th_percentile": 5.58, "90th_percentile": 152.83 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "49", "median_amount": 6.01, "10th_percentile": 6.01, "90th_percentile": 6.01 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "1 through 10", "median_amount": 4.42, "10th_percentile": 4.42, "90th_percentile": 10.71 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "1 through 10", "median_amount": 25.63, "10th_percentile": 25.63, "90th_percentile": 25.63 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "1 through 10", "median_amount": 10.73, "10th_percentile": 10.73, "90th_percentile": 10.73 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "11", "median_amount": 4.29, "10th_percentile": 4.29, "90th_percentile": 4.29 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "1 through 10", "median_amount": 152.83, "10th_percentile": 17.0, "90th_percentile": 152.83 }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 31.59, "standard_charge_algorithm": "Fee schedule rate ($31.59).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 16.45, "10th_percentile": 16.45, "90th_percentile": 16.45 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 4.29 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "29", "median_amount": 4.29, "10th_percentile": 4.29, "90th_percentile": 4.29 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3.82, "standard_charge_algorithm": "Fee schedule rate ($3.82).", "count": "127", "median_amount": 3.82, "10th_percentile": 3.82, "90th_percentile": 7.64 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 3.82, "standard_charge_algorithm": "Fee schedule rate ($3.82).", "count": "169", "median_amount": 3.82, "10th_percentile": 3.82, "90th_percentile": 3.82 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "12", "median_amount": 4.46, "10th_percentile": 4.46, "90th_percentile": 4.46 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "195", "median_amount": 4.29, "10th_percentile": 4.29, "90th_percentile": 4.29 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "354", "median_amount": 4.29, "10th_percentile": 4.29, "90th_percentile": 4.29 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "13", "median_amount": 4.46, "10th_percentile": 4.46, "90th_percentile": 4.46 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "1 through 10", "median_amount": 4.42, "10th_percentile": 4.42, "90th_percentile": 4.42 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 3.82, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Thromboplas Time Partial - Aptt", "code_information": [ { "code": "CASE-85730", "type": "LOCAL" }, { "code": "85730", "type": "CPT" }, { "code": "305", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 915.46, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 62.3, "10th_percentile": 62.3, "90th_percentile": 62.3 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 14.14, "10th_percentile": 14.14, "90th_percentile": 14.14 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 60.27, "standard_charge_algorithm": "APC Rate ($60.27). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 102.72 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 183.43 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 146.74 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 30.64, "standard_charge_algorithm": "Fee schedule rate ($30.64).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 17.27, "standard_charge_algorithm": "Case rate ($17.27). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5.35, "standard_charge_algorithm": "Fee schedule rate ($5.35).", "count": "1 through 10", "median_amount": 26.75, "10th_percentile": 5.35, "90th_percentile": 26.75 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5.35, "standard_charge_algorithm": "Fee schedule rate ($5.35).", "count": "1 through 10", "median_amount": 5.35, "10th_percentile": 5.35, "90th_percentile": 5.35 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 76.3, "standard_charge_algorithm": "Fee schedule rate ($76.30).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "standard_charge_algorithm": "Fee schedule rate ($73.37).", "count": "1 through 10", "median_amount": 6.01, "10th_percentile": 6.01, "90th_percentile": 6.01 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "standard_charge_algorithm": "Fee schedule rate ($73.37).", "count": "1 through 10", "median_amount": 6.01, "10th_percentile": 6.01, "90th_percentile": 6.01 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 75.57 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 73.37, "standard_charge_algorithm": "Fee schedule rate ($73.37).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 5.35, "maximum": 183.43, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC RBC Antibody Screen - Antibody Screen", "code_information": [ { "code": "CASE-86850", "type": "LOCAL" }, { "code": "86850", "type": "CPT" }, { "code": "300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 33938.47, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 33.12, "10th_percentile": 33.12, "90th_percentile": 33.12 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 33.6, "10th_percentile": 18.8, "90th_percentile": 41.77 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 31086.0, "standard_charge_algorithm": "Case rate ($31,086).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 26703.99, "standard_charge_algorithm": "APC Rate ($26,703.99). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 7.63, "10th_percentile": 7.63, "90th_percentile": 7.63 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 26703.99, "standard_charge_algorithm": "APC Rate ($26,703.99). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 25.28, "10th_percentile": 11.8, "90th_percentile": 31.97 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35194.04, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 62846.51, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 50.82, "10th_percentile": 50.82, "90th_percentile": 50.82 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 50277.2, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 34.61, "standard_charge_algorithm": "Fee schedule rate ($34.61).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "per diem", "standard_charge_dollar": 65249.06, "standard_charge_algorithm": "Per diem ($65,249.06). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "per diem", "standard_charge_dollar": 75037.52, "standard_charge_algorithm": "Per diem ($75,037.52). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "per diem", "standard_charge_dollar": 44947.89, "standard_charge_algorithm": "Per diem ($44,947.89). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 8.69, "standard_charge_algorithm": "Fee schedule rate ($8.69).", "count": "1 through 10", "median_amount": 43.45, "10th_percentile": 8.69, "90th_percentile": 43.45 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 8.69, "standard_charge_algorithm": "Fee schedule rate ($8.69).", "count": "1 through 10", "median_amount": 8.69, "10th_percentile": 8.69, "90th_percentile": 8.69 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 50.82, "10th_percentile": 50.82, "90th_percentile": 50.82 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25892.76, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 8.69, "maximum": 75037.52, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Blood Typing Serologic Abo", "code_information": [ { "code": "CASE-86900", "type": "LOCAL" }, { "code": "86900", "type": "CPT" }, { "code": "300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 33975.76, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 33.12, "10th_percentile": 33.12, "90th_percentile": 33.12 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 33.6, "10th_percentile": 18.8, "90th_percentile": 41.77 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 31086.0, "standard_charge_algorithm": "Case rate ($31,086).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 26703.99, "standard_charge_algorithm": "APC Rate ($26,703.99). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 7.63, "10th_percentile": 7.63, "90th_percentile": 7.63 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 26703.99, "standard_charge_algorithm": "APC Rate ($26,703.99). Final payment is multiplied by 229.17%.", "count": "11", "median_amount": 25.69, "10th_percentile": 19.81, "90th_percentile": 302.85 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35194.04, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 62846.51, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 122.61, "10th_percentile": 122.61, "90th_percentile": 122.61 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 50277.2, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 34.61, "standard_charge_algorithm": "Fee schedule rate ($34.61).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "per diem", "standard_charge_dollar": 65249.06, "standard_charge_algorithm": "Per diem ($65,249.06). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "per diem", "standard_charge_dollar": 75037.52, "standard_charge_algorithm": "Per diem ($75,037.52). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "per diem", "standard_charge_dollar": 44947.89, "standard_charge_algorithm": "Per diem ($44,947.89). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 122.61, "10th_percentile": 122.61, "90th_percentile": 122.61 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.66, "standard_charge_algorithm": "Fee schedule rate ($2.66).", "count": "1 through 10", "median_amount": 13.3, "10th_percentile": 2.66, "90th_percentile": 13.3 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.66, "standard_charge_algorithm": "Fee schedule rate ($2.66).", "count": "1 through 10", "median_amount": 2.66, "10th_percentile": 2.66, "90th_percentile": 2.66 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 122.61, "10th_percentile": 122.61, "90th_percentile": 122.61 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25892.76, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 2.66, "maximum": 75037.52, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Blood Typing Serologic Rh (D)", "code_information": [ { "code": "CASE-86901", "type": "LOCAL" }, { "code": "86901", "type": "CPT" }, { "code": "300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 33975.76, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 33.12, "10th_percentile": 33.12, "90th_percentile": 33.12 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 33.6, "10th_percentile": 18.8, "90th_percentile": 41.77 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 31086.0, "standard_charge_algorithm": "Case rate ($31,086).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 26703.99, "standard_charge_algorithm": "APC Rate ($26,703.99). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 7.63, "10th_percentile": 7.63, "90th_percentile": 7.63 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 26703.99, "standard_charge_algorithm": "APC Rate ($26,703.99). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 25.28, "10th_percentile": 11.8, "90th_percentile": 31.97 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35194.04, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 62846.51, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 50277.2, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 34.61, "standard_charge_algorithm": "Fee schedule rate ($34.61).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "per diem", "standard_charge_dollar": 65249.06, "standard_charge_algorithm": "Per diem ($65,249.06). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "per diem", "standard_charge_dollar": 75037.52, "standard_charge_algorithm": "Per diem ($75,037.52). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "per diem", "standard_charge_dollar": 44947.89, "standard_charge_algorithm": "Per diem ($44,947.89). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "per diem", "standard_charge_dollar": 35422.8, "standard_charge_algorithm": "Per diem ($35,422.80). Maximum number of claim lines to pay is 1.", "count": "0", "additional_payer_notes": "Estimated amount calculated based on 1 day length of stay. Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.66, "standard_charge_algorithm": "Fee schedule rate ($2.66).", "count": "1 through 10", "median_amount": 13.3, "10th_percentile": 2.66, "90th_percentile": 13.3 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 2.66, "standard_charge_algorithm": "Fee schedule rate ($2.66).", "count": "1 through 10", "median_amount": 2.66, "10th_percentile": 2.66, "90th_percentile": 2.66 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25892.76, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 25138.6, "standard_charge_algorithm": "APC Price ($25,138.60). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 2.66, "maximum": 75037.52, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Electronic Crossmatch", "code_information": [ { "code": "CASE-86923", "type": "LOCAL" }, { "code": "86923", "type": "CPT" }, { "code": "300", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 2097.32, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 450.73, "standard_charge_algorithm": "APC Rate ($450.73). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 450.73, "standard_charge_algorithm": "APC Rate ($450.73). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 424.31, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 594.03, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1060.77, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 424.31, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 848.62, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 4947.22, "standard_charge_algorithm": "Case rate ($4,947.22). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 424.31, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 5689.39, "standard_charge_algorithm": "Case rate ($5,689.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 3407.97, "standard_charge_algorithm": "Case rate ($3,407.97). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2685.78, "standard_charge_algorithm": "Case rate ($2,685.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2685.78, "standard_charge_algorithm": "Case rate ($2,685.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2685.78, "standard_charge_algorithm": "Case rate ($2,685.78). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 424.31, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 397.28, "standard_charge_algorithm": "Fee schedule rate ($397.28).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 397.28, "standard_charge_algorithm": "Fee schedule rate ($397.28).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 424.31, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 424.31, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 424.31, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 424.31, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 424.31, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 437.04, "standard_charge_algorithm": "APC Price ($424.31). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 424.31, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 397.28, "maximum": 5689.39, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Blood Culture for Bacteria", "code_information": [ { "code": "CASE-87040", "type": "LOCAL" }, { "code": "87040", "type": "CPT" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 149.69, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 22.08, "10th_percentile": 22.08, "90th_percentile": 22.08 }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "standard_charge_algorithm": "Fee schedule rate ($10.32).", "count": "1 through 10", "median_amount": 10.32, "10th_percentile": 10.32, "90th_percentile": 10.32 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "standard_charge_algorithm": "Fee schedule rate ($10.32).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 10.32 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 14.45 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 25.8 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 10.32 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 20.64 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 23.07, "standard_charge_algorithm": "Fee schedule rate ($23.07).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 125.21, "standard_charge_algorithm": "Case rate ($125.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 10.32 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 125.21, "standard_charge_algorithm": "Case rate ($125.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 125.21, "standard_charge_algorithm": "Case rate ($125.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 125.21, "standard_charge_algorithm": "Case rate ($125.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 125.21, "standard_charge_algorithm": "Case rate ($125.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 125.21, "standard_charge_algorithm": "Case rate ($125.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.32 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 9.18, "standard_charge_algorithm": "Fee schedule rate ($9.18).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 9.18, "standard_charge_algorithm": "Fee schedule rate ($9.18).", "count": "1 through 10", "median_amount": 9.18, "10th_percentile": 9.18, "90th_percentile": 9.18 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.73, "standard_charge_algorithm": "Fee schedule rate ($10.73).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.32 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "standard_charge_algorithm": "Fee schedule rate ($10.32).", "count": "1 through 10", "median_amount": 10.32, "10th_percentile": 10.32, "90th_percentile": 10.32 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "standard_charge_algorithm": "Fee schedule rate ($10.32).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.32 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.63 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 10.32, "standard_charge_algorithm": "Fee schedule rate ($10.32).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 9.18, "maximum": 125.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cul Bact Xcpt Urine Blood/Stool Aerobic Isol", "code_information": [ { "code": "CASE-87070", "type": "LOCAL" }, { "code": "87070", "type": "CPT" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 219.35, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 25.53, "10th_percentile": 25.53, "90th_percentile": 25.53 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 77.7, "10th_percentile": 25.9, "90th_percentile": 77.7 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 106.81, "standard_charge_algorithm": "APC Rate ($106.81). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 106.81, "standard_charge_algorithm": "APC Rate ($106.81). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 8.62, "10th_percentile": 8.62, "90th_percentile": 8.62 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 140.77, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 12.07, "10th_percentile": 12.07, "90th_percentile": 12.07 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 251.37, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 201.1, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 26.68, "standard_charge_algorithm": "Fee schedule rate ($26.68).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 8.62, "10th_percentile": 8.62, "90th_percentile": 8.62 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7.67, "standard_charge_algorithm": "Fee schedule rate ($7.67).", "count": "1 through 10", "median_amount": 7.67, "10th_percentile": 7.67, "90th_percentile": 7.67 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7.67, "standard_charge_algorithm": "Fee schedule rate ($7.67).", "count": "1 through 10", "median_amount": 7.67, "10th_percentile": 7.67, "90th_percentile": 7.67 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 8.62, "10th_percentile": 8.62, "90th_percentile": 25.59 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "15", "median_amount": 8.62, "10th_percentile": 8.62, "90th_percentile": 8.62 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 8.96, "10th_percentile": 8.96, "90th_percentile": 8.96 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 103.57, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 100.55, "standard_charge_algorithm": "APC Price ($100.55). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 7.67, "maximum": 251.37, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cultr Bacteria Except Blood", "code_information": [ { "code": "CASE-87075", "type": "LOCAL" }, { "code": "87075", "type": "CPT" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 533.35, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 32.2, "10th_percentile": 32.2, "90th_percentile": 32.2 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 9.47 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 8.42, "standard_charge_algorithm": "Fee schedule rate ($8.42).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 8.42, "standard_charge_algorithm": "Fee schedule rate ($8.42).", "count": "1 through 10", "median_amount": 8.42, "10th_percentile": 8.42, "90th_percentile": 8.42 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 8.42, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Culture Strep Group A", "code_information": [ { "code": "CASE-87081", "type": "LOCAL" }, { "code": "87081", "type": "CPT" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1762.83, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1532.0, "standard_charge_algorithm": "Case rate ($1,532). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1818.45, "standard_charge_algorithm": "APC Rate ($1,818.45). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 1818.45, "standard_charge_algorithm": "APC Rate ($1,818.45). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2396.59, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 4279.63, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3423.7, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6904.64, "standard_charge_algorithm": "Case rate ($6,904.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 7940.46, "standard_charge_algorithm": "Case rate ($7,940.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5.9, "standard_charge_algorithm": "Fee schedule rate ($5.90).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5.9, "standard_charge_algorithm": "Fee schedule rate ($5.90).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1763.21, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1711.85, "standard_charge_algorithm": "APC Price ($1,711.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 5.9, "maximum": 7940.46, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Culture Urine Quant", "code_information": [ { "code": "CASE-87086", "type": "LOCAL" }, { "code": "87086", "type": "CPT" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 233.41, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 20.7, "10th_percentile": 20.7, "90th_percentile": 20.7 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 8.07, "10th_percentile": 8.07, "90th_percentile": 8.07 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 7.5, "10th_percentile": 7.5, "90th_percentile": 7.5 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 21.63, "standard_charge_algorithm": "Fee schedule rate ($21.63).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 8.07 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7.18, "standard_charge_algorithm": "Fee schedule rate ($7.18).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7.18, "standard_charge_algorithm": "Fee schedule rate ($7.18).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 8.39, "10th_percentile": 8.39, "90th_percentile": 8.39 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 8.07, "10th_percentile": 8.07, "90th_percentile": 8.07 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 8.07, "10th_percentile": 8.07, "90th_percentile": 8.07 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 7.18, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Antibiotic Sens,Mic,Each - Susceptibility Charge", "code_information": [ { "code": "CASE-87186", "type": "LOCAL" }, { "code": "87186", "type": "CPT" }, { "code": "306", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 290.83, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "standard_charge_algorithm": "Fee schedule rate ($17.30).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "standard_charge_algorithm": "Fee schedule rate ($17.30).", "count": "1 through 10", "median_amount": 8.65, "10th_percentile": 8.65, "90th_percentile": 8.65 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "fee schedule", "standard_charge_dollar": 17.3 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "fee schedule", "standard_charge_dollar": 24.22 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "fee schedule", "standard_charge_dollar": 43.25 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "fee schedule", "standard_charge_dollar": 17.3 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "fee schedule", "standard_charge_dollar": 34.6 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "fee schedule", "standard_charge_dollar": 17.3 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 34.46, "standard_charge_algorithm": "Case rate ($34.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.3 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7.69, "standard_charge_algorithm": "Fee schedule rate ($7.69).", "count": "1 through 10", "median_amount": 7.69, "10th_percentile": 7.69, "90th_percentile": 7.69 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 7.69, "standard_charge_algorithm": "Fee schedule rate ($7.69).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.99, "standard_charge_algorithm": "Fee schedule rate ($17.99).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.3 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "standard_charge_algorithm": "Fee schedule rate ($17.30).", "count": "1 through 10", "median_amount": 8.65, "10th_percentile": 8.65, "90th_percentile": 8.65 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "standard_charge_algorithm": "Fee schedule rate ($17.30).", "count": "20", "median_amount": 8.65, "10th_percentile": 8.65, "90th_percentile": 17.3 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.3 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.82 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 17.3, "standard_charge_algorithm": "Fee schedule rate ($17.30).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ], "minimum": 7.69, "maximum": 43.25, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cytopath Cell Enhance Tech - Lab Cytopath, Cell Enhance Tech", "code_information": [ { "code": "CASE-88112", "type": "LOCAL" }, { "code": "88112", "type": "CPT" }, { "code": "311", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1765.87, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1532.0, "standard_charge_algorithm": "Case rate ($1,532). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3809.1, "standard_charge_algorithm": "APC Rate ($3,809.10). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 3809.1, "standard_charge_algorithm": "APC Rate ($3,809.10). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5020.13, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 8964.53, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7171.62, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 6904.64, "standard_charge_algorithm": "Case rate ($6,904.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 7940.46, "standard_charge_algorithm": "Case rate ($7,940.46). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 193.39, "standard_charge_algorithm": "Case rate ($193.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 193.39, "standard_charge_algorithm": "Case rate ($193.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 193.39, "standard_charge_algorithm": "Case rate ($193.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 193.39, "standard_charge_algorithm": "Case rate ($193.39). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 33.17, "standard_charge_algorithm": "Fee schedule rate ($33.17).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 33.17, "standard_charge_algorithm": "Fee schedule rate ($33.17).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3693.38, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 3585.81, "standard_charge_algorithm": "APC Price ($3,585.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 33.17, "maximum": 8964.53, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Flowcytometry/ Tech Component, 1 Marker - Tech Cmp", "code_information": [ { "code": "CASE-88184", "type": "LOCAL" }, { "code": "88184", "type": "CPT" }, { "code": "311", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1979.31, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 640.89, "standard_charge_algorithm": "APC Rate ($640.89). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 640.89, "standard_charge_algorithm": "APC Rate ($640.89). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 844.65, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1508.3, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1206.64, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 4153.58, "standard_charge_algorithm": "Case rate ($4,153.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 4776.68, "standard_charge_algorithm": "Case rate ($4,776.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 2861.26, "standard_charge_algorithm": "Case rate ($2,861.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 63.07, "standard_charge_algorithm": "Fee schedule rate ($63.07).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 63.07, "standard_charge_algorithm": "Fee schedule rate ($63.07).", "count": "1 through 10", "median_amount": 64.93, "10th_percentile": 64.93, "90th_percentile": 64.93 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 342.17, "10th_percentile": 342.17, "90th_percentile": 342.17 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 621.42, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 63.07, "maximum": 4776.68, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Flowcytometry/Tech Component, Add-on - Tech Cmp", "code_information": [ { "code": "CASE-88185", "type": "LOCAL" }, { "code": "88185", "type": "CPT" }, { "code": "311", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1979.31, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 640.89, "standard_charge_algorithm": "APC Rate ($640.89). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 640.89, "standard_charge_algorithm": "APC Rate ($640.89). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 844.65, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1508.3, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1206.64, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 4153.58, "standard_charge_algorithm": "Case rate ($4,153.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 4776.68, "standard_charge_algorithm": "Case rate ($4,776.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 2861.26, "standard_charge_algorithm": "Case rate ($2,861.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 18.35, "standard_charge_algorithm": "Fee schedule rate ($18.35).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 18.35, "standard_charge_algorithm": "Fee schedule rate ($18.35).", "count": "1 through 10", "median_amount": 19.72, "10th_percentile": 19.72, "90th_percentile": 19.72 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 621.42, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 18.35, "maximum": 4776.68, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Surg Path,Level IV - Lab Surg Path,Level IV", "code_information": [ { "code": "CASE-88305", "type": "LOCAL" }, { "code": "88305", "type": "CPT" }, { "code": "312", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1734.05, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "fee schedule", "standard_charge_dollar": 1143.0, "standard_charge_algorithm": "Case rate ($1,143). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 1 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 640.89, "standard_charge_algorithm": "APC Rate ($640.89). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 640.89, "standard_charge_algorithm": "APC Rate ($640.89). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 844.65, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1508.3, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1206.64, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 4153.58, "standard_charge_algorithm": "Case rate ($4,153.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 4776.68, "standard_charge_algorithm": "Case rate ($4,776.68). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 2861.26, "standard_charge_algorithm": "Case rate ($2,861.26). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2254.92, "standard_charge_algorithm": "Case rate ($2,254.92). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 28.85, "standard_charge_algorithm": "Fee schedule rate ($28.85).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 28.85, "standard_charge_algorithm": "Fee schedule rate ($28.85).", "count": "1 through 10", "median_amount": 29.69, "10th_percentile": 29.69, "90th_percentile": 29.69 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 50.82, "10th_percentile": 50.82, "90th_percentile": 50.82 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 621.42, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 603.32, "standard_charge_algorithm": "APC Price ($603.32). If the procedure is the highest rate for the service date, then the payment is multiplied by ( 1 plus (0.5 times the quantity minus 1 )) divided by the quantity. Otherwise the payment is multiplied by 0.5. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 28.85, "maximum": 4776.68, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Flulaval Trivalent Pf Vaccine 2024/2025", "code_information": [ { "code": "CASE-90656", "type": "LOCAL" }, { "code": "90656", "type": "CPT" }, { "code": "636", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 4011.91, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 58.0, "standard_charge_algorithm": "58% of billed.", "count": "1 through 10", "median_amount": 34.12, "10th_percentile": 34.12, "90th_percentile": 34.12 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 58.0, "standard_charge_algorithm": "58% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "case rate", "standard_charge_dollar": 1726.0, "standard_charge_algorithm": "Case rate ($1,726).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2672.15, "standard_charge_algorithm": "APC Rate ($2,672.15). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 17.52, "10th_percentile": 17.52, "90th_percentile": 17.52 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 2672.15, "standard_charge_algorithm": "APC Rate ($2,672.15). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 20.77, "10th_percentile": 17.52, "90th_percentile": 20.77 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 3521.71, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 11.94, "10th_percentile": 11.94, "90th_percentile": 20.09 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 40.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 6288.77, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 59.62, "10th_percentile": 59.62, "90th_percentile": 59.62 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 50.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 50.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5031.02, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 21.74, "standard_charge_algorithm": "Fee schedule rate ($21.74).", "count": "1 through 10", "median_amount": 63.6, "10th_percentile": 21.74, "90th_percentile": 63.6 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 21.74, "standard_charge_algorithm": "Fee schedule rate ($21.74).", "count": "1 through 10", "median_amount": 21.74, "10th_percentile": 20.93, "90th_percentile": 122.19 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 8.87, "10th_percentile": 8.87, "90th_percentile": 18.43 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "16", "median_amount": 17.72, "10th_percentile": 8.53, "90th_percentile": 29.81 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "59", "median_amount": 14.35, "10th_percentile": 8.53, "90th_percentile": 29.81 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 8.87, "10th_percentile": 8.87, "90th_percentile": 8.87 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2590.97, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 2515.51, "standard_charge_algorithm": "APC Price ($2,515.51). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 21.74, "maximum": 6288.77, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Tetanus-Diphth-Acell Pertussis Vaccine", "code_information": [ { "code": "CASE-90715", "type": "LOCAL" }, { "code": "90715", "type": "CPT" }, { "code": "636", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 23597.71, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 58.0, "standard_charge_algorithm": "58% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 58.0, "standard_charge_algorithm": "58% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 7000.0, "standard_charge_algorithm": "Fee schedule rate ($7,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 18728.69, "standard_charge_algorithm": "APC Rate ($18,728.69). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 24683.14, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 40.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 44077.04, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 50.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 50.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35261.63, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 50964.65, "standard_charge_algorithm": "Case rate ($50,964.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 58610.21, "standard_charge_algorithm": "Case rate ($58,610.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 35107.84, "standard_charge_algorithm": "Case rate ($35,107.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 16507.73, "standard_charge_algorithm": "Case rate ($16,507.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 16507.73, "standard_charge_algorithm": "Case rate ($16,507.73). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 18159.74, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 17630.81, "standard_charge_algorithm": "APC Price ($17,630.81). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 7000.0, "maximum": 58610.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Prq Trluml Coronary Angioplasty One Art/Branch and/or It's Branches", "code_information": [ { "code": "CASE-92920", "type": "LOCAL" }, { "code": "92920", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 12484.24, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 7000.0, "standard_charge_algorithm": "Fee schedule rate ($7,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 11362.99, "standard_charge_algorithm": "Case rate ($11,362.99). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 50964.65, "standard_charge_algorithm": "Case rate ($50,964.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 58610.21, "standard_charge_algorithm": "Case rate ($58,610.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 35107.84, "standard_charge_algorithm": "Case rate ($35,107.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5125.28, "standard_charge_algorithm": "Case rate ($5,125.28). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5125.28, "standard_charge_algorithm": "Case rate ($5,125.28). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "1 through 10", "median_amount": 5139.46, "10th_percentile": 5139.46, "90th_percentile": 5139.46 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 5423.4, "10th_percentile": 5004.4, "90th_percentile": 5423.4 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 5125.28, "maximum": 58610.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Prq Trluml Coronary Angioplasty Addl Branch", "code_information": [ { "code": "CASE-92921", "type": "LOCAL" }, { "code": "92921", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 21772.06, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 7000.0, "standard_charge_algorithm": "Fee schedule rate ($7,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 15543.99, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 11118.33, "standard_charge_algorithm": "Case rate ($11,118.33). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 27757.13, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 22205.7, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 50964.65, "standard_charge_algorithm": "Case rate ($50,964.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 58610.21, "standard_charge_algorithm": "Case rate ($58,610.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 35107.84, "standard_charge_algorithm": "Case rate ($35,107.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 10395.6, "standard_charge_algorithm": "Case rate ($10,395.60). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 10395.6, "standard_charge_algorithm": "Case rate ($10,395.60). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11435.94, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 7000.0, "maximum": 58610.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Prq Trluml Coronary Stent W/Angio One Art/Brnch and/or It's Branches", "code_information": [ { "code": "CASE-92928", "type": "LOCAL" }, { "code": "92928", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 17979.83, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 7000.0, "standard_charge_algorithm": "Fee schedule rate ($7,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 15543.99, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 23869.36, "standard_charge_algorithm": "Case rate ($23,869.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 27757.13, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 22205.7, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 50964.65, "standard_charge_algorithm": "Case rate ($50,964.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 58610.21, "standard_charge_algorithm": "Case rate ($58,610.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 35107.84, "standard_charge_algorithm": "Case rate ($35,107.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 10395.6, "standard_charge_algorithm": "Case rate ($10,395.60). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "1 through 10", "median_amount": 7877.66, "10th_percentile": 7877.66, "90th_percentile": 9950.28 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 10395.6, "standard_charge_algorithm": "Case rate ($10,395.60). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "1 through 10", "median_amount": 24271.61, "10th_percentile": 24271.61, "90th_percentile": 24271.61 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11435.94, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 7000.0, "maximum": 58610.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Prq Trluml Coronary Stent W/Angio Addl Art/Brnch", "code_information": [ { "code": "CASE-92929", "type": "LOCAL" }, { "code": "92929", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 25741.52, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 7000.0, "standard_charge_algorithm": "Fee schedule rate ($7,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 15543.99, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 23869.36, "standard_charge_algorithm": "Case rate ($23,869.36). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 55.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 27757.13, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 22205.7, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 50964.65, "standard_charge_algorithm": "Case rate ($50,964.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 58610.21, "standard_charge_algorithm": "Case rate ($58,610.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 35107.84, "standard_charge_algorithm": "Case rate ($35,107.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 10395.6, "standard_charge_algorithm": "Case rate ($10,395.60). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 10395.6, "standard_charge_algorithm": "Case rate ($10,395.60). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11435.94, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 7000.0, "maximum": 58610.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Prq Trluml Coronry Chronic Occlus Revasc One Vsl", "code_information": [ { "code": "CASE-92943", "type": "LOCAL" }, { "code": "92943", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 15198.32, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 7000.0, "standard_charge_algorithm": "Fee schedule rate ($7,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 11794.23, "standard_charge_algorithm": "APC Rate ($11,794.23). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 15543.99, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 31483.15, "standard_charge_algorithm": "Case rate ($31,483.15). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 27757.13, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 22205.7, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 50964.65, "standard_charge_algorithm": "Case rate ($50,964.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 58610.21, "standard_charge_algorithm": "Case rate ($58,610.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 35107.84, "standard_charge_algorithm": "Case rate ($35,107.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 10395.6, "standard_charge_algorithm": "Case rate ($10,395.60). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 10395.6, "standard_charge_algorithm": "Case rate ($10,395.60). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 10787.38, "10th_percentile": 10787.38, "90th_percentile": 10787.38 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11435.94, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 11102.85, "standard_charge_algorithm": "APC Price ($11,102.85). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 7000.0, "maximum": 58610.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cardioversion, Elective;Extern", "code_information": [ { "code": "CASE-92960", "type": "LOCAL" }, { "code": "92960", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1619.2, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 1095.13, "10th_percentile": 647.36, "90th_percentile": 1095.13 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 1111.01, "10th_percentile": 1111.01, "90th_percentile": 1111.01 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 675.26, "standard_charge_algorithm": "APC Rate ($675.26). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 955.47, "10th_percentile": 955.47, "90th_percentile": 955.47 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 675.26, "standard_charge_algorithm": "APC Rate ($675.26). Final payment is multiplied by 229.17%.", "count": "18", "median_amount": 1537.46, "10th_percentile": 822.74, "90th_percentile": 1537.46 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 809.2, "10th_percentile": 809.2, "90th_percentile": 809.2 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 635.68, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 889.95, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 871.44, "10th_percentile": 871.44, "90th_percentile": 871.44 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 1585.82, "standard_charge_algorithm": "Case rate ($1,585.82). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1589.19, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 635.68, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 622.46, "10th_percentile": 569.83, "90th_percentile": 622.46 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1271.35, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 750.89, "standard_charge_algorithm": "Fee schedule rate ($750.89).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 3771.62, "standard_charge_algorithm": "Case rate ($3,771.62). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 635.68, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 4337.43, "standard_charge_algorithm": "Case rate ($4,337.43). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 2598.14, "standard_charge_algorithm": "Case rate ($2,598.14). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 2047.56, "standard_charge_algorithm": "Case rate ($2,047.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 2047.56, "standard_charge_algorithm": "Case rate ($2,047.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 2047.56, "standard_charge_algorithm": "Case rate ($2,047.56). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 635.68, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 622.46, "10th_percentile": 622.46, "90th_percentile": 622.46 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 595.18, "standard_charge_algorithm": "Case rate ($595.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "1 through 10", "median_amount": 1554.24, "10th_percentile": 525.61, "90th_percentile": 1554.24 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 595.18, "standard_charge_algorithm": "Case rate ($595.18). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%.", "count": "1 through 10", "median_amount": 582.74, "10th_percentile": 0.84, "90th_percentile": 582.74 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 635.68, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 647.36, "10th_percentile": 647.36, "90th_percentile": 647.36 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 635.68, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 635.68, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "57", "median_amount": 622.46, "10th_percentile": 622.46, "90th_percentile": 622.46 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 635.68, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "115", "median_amount": 622.46, "10th_percentile": 622.46, "90th_percentile": 622.46 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 635.68, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 647.36, "10th_percentile": 647.36, "90th_percentile": 647.36 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 654.75, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 635.68, "standard_charge_algorithm": "APC Price ($635.68). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 595.18, "maximum": 4337.43, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Cath Transcath Placmt,Rad Deliv Dev,Coronary", "code_information": [ { "code": "CASE-92974", "type": "LOCAL" }, { "code": "92974", "type": "CPT" }, { "code": "481", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 12970.85, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "fee schedule", "standard_charge_dollar": 7000.0, "standard_charge_algorithm": "Fee schedule rate ($7,000).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "case rate", "standard_charge_dollar": 29605.0, "standard_charge_algorithm": "Case rate ($29,605).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 5814.84, "standard_charge_algorithm": "APC Rate ($5,814.84). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 7663.56, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 3196.17, "standard_charge_algorithm": "Case rate ($3,196.17). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 13684.94, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 10947.95, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 50964.65, "standard_charge_algorithm": "Case rate ($50,964.65). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 58610.21, "standard_charge_algorithm": "Case rate ($58,610.21). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 35107.84, "standard_charge_algorithm": "Case rate ($35,107.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 27668.0, "standard_charge_algorithm": "Case rate ($27,668.00). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 99999 procedures at 0%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 135.44, "standard_charge_algorithm": "Fee schedule rate ($135.44).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 135.44, "standard_charge_algorithm": "Fee schedule rate ($135.44).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5638.19, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 5473.97, "standard_charge_algorithm": "APC Price ($5,473.97). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 135.44, "maximum": 58610.21, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Electrocardiogram, Tracing", "code_information": [ { "code": "CASE-93005", "type": "LOCAL" }, { "code": "93005", "type": "CPT" }, { "code": "730", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 156.97, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "485", "median_amount": 90.74, "10th_percentile": 90.74, "90th_percentile": 90.74 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "480", "median_amount": 92.05, "10th_percentile": 92.05, "90th_percentile": 92.05 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "70", "median_amount": 88.77, "10th_percentile": 84.73, "90th_percentile": 104.62 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "1 through 10", "median_amount": 5.25, "10th_percentile": 5.25, "90th_percentile": 5.25 }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 136.02, "standard_charge_algorithm": "APC Rate ($136.02). Final payment is multiplied by 229.17%.", "count": "589", "median_amount": 88.77, "10th_percentile": 73.24, "90th_percentile": 131.5 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "64", "median_amount": 73.45, "10th_percentile": 69.63, "90th_percentile": 73.45 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 59.4, "10th_percentile": 59.4, "90th_percentile": 59.4 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 179.27, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "21", "median_amount": 79.1, "10th_percentile": 79.1, "90th_percentile": 79.1 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "1 through 10", "median_amount": 58.2, "10th_percentile": 58.2, "90th_percentile": 82.85 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "1 through 10", "median_amount": 78.9, "10th_percentile": 32.88, "90th_percentile": 131.5 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "98", "median_amount": 32.88, "10th_percentile": 32.88, "90th_percentile": 32.88 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "1 through 10", "median_amount": 65.75, "10th_percentile": 62.15, "90th_percentile": 117.84 }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 320.12, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "18", "median_amount": 131.5, "10th_percentile": 131.5, "90th_percentile": 131.5 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "99", "median_amount": 56.5, "10th_percentile": 56.5, "90th_percentile": 56.5 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "1 through 10", "median_amount": 74.98, "10th_percentile": 74.98, "90th_percentile": 74.98 }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "1 through 10", "median_amount": 79.1, "10th_percentile": 32.51, "90th_percentile": 79.1 }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 256.09, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 92.05, "10th_percentile": 92.05, "90th_percentile": 92.05 }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 53.62, "standard_charge_algorithm": "Fee schedule rate ($53.62).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "36", "median_amount": 69.7, "10th_percentile": 69.7, "90th_percentile": 69.7 }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "70", "median_amount": 61.81, "10th_percentile": 61.81, "90th_percentile": 61.81 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 42.23, "standard_charge_algorithm": "Case rate ($42.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "21", "median_amount": 40.21, "10th_percentile": 40.21, "90th_percentile": 40.21 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 56.74, "standard_charge_algorithm": "APC Price ($56.74). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 42.23, "standard_charge_algorithm": "Case rate ($42.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 40.21, "10th_percentile": 40.21, "90th_percentile": 40.21 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 42.23, "standard_charge_algorithm": "Case rate ($42.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "33", "median_amount": 40.21, "10th_percentile": 40.21, "90th_percentile": 40.21 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 42.23, "standard_charge_algorithm": "Case rate ($42.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "53", "median_amount": 40.21, "10th_percentile": 40.21, "90th_percentile": 40.21 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 42.23, "standard_charge_algorithm": "Case rate ($42.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 42.23, "standard_charge_algorithm": "Case rate ($42.23). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 40.21, "10th_percentile": 40.21, "90th_percentile": 40.21 }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "14", "median_amount": 56.5, "10th_percentile": 56.5, "90th_percentile": 56.5 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5.1, "standard_charge_algorithm": "Fee schedule rate ($5.10).", "count": "385", "median_amount": 52.12, "10th_percentile": 10.5, "90th_percentile": 156.36 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 5.1, "standard_charge_algorithm": "Fee schedule rate ($5.10).", "count": "433", "median_amount": 5.25, "10th_percentile": 5.1, "90th_percentile": 5.25 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "11", "median_amount": 58.76, "10th_percentile": 58.76, "90th_percentile": 58.76 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "30", "median_amount": 56.5, "10th_percentile": 56.5, "90th_percentile": 56.5 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "60367", "median_amount": 137.58, "10th_percentile": 137.58, "90th_percentile": 137.58 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "214", "median_amount": 56.5, "10th_percentile": 53.56, "90th_percentile": 56.5 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 58.76, "10th_percentile": 58.76, "90th_percentile": 58.76 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 131.89, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "36", "median_amount": 58.2, "10th_percentile": 55.17, "90th_percentile": 58.2 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 128.05, "standard_charge_algorithm": "APC Price ($128.05). The procedure can be bundled into a comprehensive APC if other services qualifying for that comprehensive APC are present. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 5.1, "maximum": 320.12, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Patch Monitor Hook-Up; 8 Days to 15 Days", "code_information": [ { "code": "CASE-93246", "type": "LOCAL" }, { "code": "93246", "type": "CPT" }, { "code": "731", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 68.17, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "15", "median_amount": 134.38, "10th_percentile": 134.38, "90th_percentile": 134.38 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 136.33, "10th_percentile": 136.33, "90th_percentile": 136.33 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 38.16, "standard_charge_algorithm": "APC Rate ($38.16). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 92.22, "10th_percentile": 92.22, "90th_percentile": 92.22 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "1 through 10", "median_amount": 9.97, "10th_percentile": 9.97, "90th_percentile": 9.97 }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 38.16, "standard_charge_algorithm": "APC Rate ($38.16). Final payment is multiplied by 229.17%.", "count": "39", "median_amount": 92.22, "10th_percentile": 87.68, "90th_percentile": 127.06 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 48.54, "10th_percentile": 45.64, "90th_percentile": 48.54 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35.92, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 50.29, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 52.28, "10th_percentile": 52.28, "90th_percentile": 52.28 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "percent of total billed charges", "standard_charge_percentage": 63.0, "count": "1 through 10", "median_amount": 38.46, "10th_percentile": 38.46, "90th_percentile": 38.46 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "1 through 10", "median_amount": 91.54, "10th_percentile": 91.54, "90th_percentile": 91.54 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 48.69, "10th_percentile": 48.69, "90th_percentile": 48.69 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 89.81, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35.92, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 71.85, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "1 through 10", "median_amount": 91.54, "10th_percentile": 91.54, "90th_percentile": 91.54 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 452.4, "standard_charge_algorithm": "Case rate ($452.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 452.4, "standard_charge_algorithm": "Case rate ($452.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 452.4, "standard_charge_algorithm": "Case rate ($452.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 452.4, "standard_charge_algorithm": "Case rate ($452.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 194.76, "10th_percentile": 194.76, "90th_percentile": 194.76 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 452.4, "standard_charge_algorithm": "Case rate ($452.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 452.4, "standard_charge_algorithm": "Case rate ($452.40). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.92, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 37.34, "10th_percentile": 37.34, "90th_percentile": 37.34 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 9.42, "standard_charge_algorithm": "Fee schedule rate ($9.42).", "count": "13", "median_amount": 34.44, "10th_percentile": 9.97, "90th_percentile": 103.32 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 9.42, "standard_charge_algorithm": "Fee schedule rate ($9.42).", "count": "14", "median_amount": 9.97, "10th_percentile": 9.42, "90th_percentile": 9.97 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.92, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 38.83, "10th_percentile": 38.83, "90th_percentile": 38.83 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.92, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 37.34, "10th_percentile": 37.34, "90th_percentile": 37.34 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.92, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "23", "median_amount": 37.34, "10th_percentile": 35.11, "90th_percentile": 37.34 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.92, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "61", "median_amount": 37.34, "10th_percentile": 35.11, "90th_percentile": 37.34 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35.92, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 37.0, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "1 through 10", "median_amount": 38.46, "10th_percentile": 36.16, "90th_percentile": 38.46 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35.92, "standard_charge_algorithm": "APC Price ($35.92). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 9.42, "maximum": 452.4, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Ep Interrogation Eval in Person 1/Dual/Mlt Lead Pm", "code_information": [ { "code": "CASE-93288", "type": "LOCAL" }, { "code": "93288", "type": "CPT" }, { "code": "480", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 52.5, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 103.5, "10th_percentile": 103.5, "90th_percentile": 103.5 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "13", "median_amount": 105.0, "10th_percentile": 105.0, "90th_percentile": 105.0 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 38.13, "standard_charge_algorithm": "APC Rate ($38.13). Final payment is multiplied by 229.17%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 38.13, "standard_charge_algorithm": "APC Rate ($38.13). Final payment is multiplied by 229.17%.", "count": "26", "median_amount": 87.61, "10th_percentile": 75.88, "90th_percentile": 87.61 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 46.11, "10th_percentile": 46.11, "90th_percentile": 46.11 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 50.25, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 49.66, "10th_percentile": 49.66, "90th_percentile": 49.66 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 150.0, "standard_charge_algorithm": "Case rate ($150). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "1 through 10", "median_amount": 34.01, "10th_percentile": 34.01, "90th_percentile": 34.01 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "1 through 10", "median_amount": 58.53, "10th_percentile": 54.48, "90th_percentile": 58.53 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "1 through 10", "median_amount": 37.5, "10th_percentile": 37.5, "90th_percentile": 37.5 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 89.74, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 35.47, "10th_percentile": 35.47, "90th_percentile": 35.47 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 71.79, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "1 through 10", "median_amount": 79.5, "10th_percentile": 79.5, "90th_percentile": 79.5 }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "17", "median_amount": 35.47, "10th_percentile": 35.47, "90th_percentile": 35.47 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 28.58, "standard_charge_algorithm": "Fee schedule rate ($28.58).", "count": "1 through 10", "median_amount": 48.07, "10th_percentile": 32.72, "90th_percentile": 48.07 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 28.58, "standard_charge_algorithm": "Fee schedule rate ($28.58).", "count": "1 through 10", "median_amount": 29.97, "10th_percentile": 28.58, "90th_percentile": 29.97 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "11", "median_amount": 36.89, "10th_percentile": 36.89, "90th_percentile": 36.89 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 35.47, "10th_percentile": 33.02, "90th_percentile": 35.47 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "68", "median_amount": 35.47, "10th_percentile": 35.47, "90th_percentile": 35.47 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "205", "median_amount": 35.47, "10th_percentile": 35.47, "90th_percentile": 35.47 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 36.89, "10th_percentile": 36.89, "90th_percentile": 36.89 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 36.97, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "24", "median_amount": 36.53, "10th_percentile": 36.53, "90th_percentile": 36.53 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 28.58, "maximum": 150.0, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Ilr Device Interrogat Remote - Card Device Remote - Loop Recorder", "code_information": [ { "code": "CASE-93298", "type": "LOCAL" }, { "code": "93298", "type": "CPT" }, { "code": "480", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 37.8, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "220", "median_amount": 74.52, "10th_percentile": 74.52, "90th_percentile": 74.52 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "96", "median_amount": 75.6, "10th_percentile": 75.6, "90th_percentile": 75.6 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 38.13, "standard_charge_algorithm": "APC Rate ($38.13). Final payment is multiplied by 229.17%.", "count": "29", "median_amount": 87.61, "10th_percentile": 87.61, "90th_percentile": 87.61 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 38.13, "standard_charge_algorithm": "APC Rate ($38.13). Final payment is multiplied by 229.17%.", "count": "428", "median_amount": 87.61, "10th_percentile": 82.45, "90th_percentile": 87.61 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 46.11, "10th_percentile": 46.11, "90th_percentile": 81.0 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "1 through 10", "median_amount": 74.52, "10th_percentile": 74.52, "90th_percentile": 74.52 }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 50.25, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "85", "median_amount": 49.66, "10th_percentile": 49.66, "90th_percentile": 49.66 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 108.03, "standard_charge_algorithm": "Case rate ($108.03). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "27", "median_amount": 36.53, "10th_percentile": 36.53, "90th_percentile": 36.53 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "1 through 10", "median_amount": 50.76, "10th_percentile": 50.76, "90th_percentile": 50.76 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "67", "median_amount": 27.0, "10th_percentile": 27.0, "90th_percentile": 27.0 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 89.74, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "135", "median_amount": 35.47, "10th_percentile": 33.02, "90th_percentile": 35.47 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 71.79, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "80", "median_amount": 50.76, "10th_percentile": 50.76, "90th_percentile": 50.76 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 108.0, "10th_percentile": 108.0, "90th_percentile": 108.0 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 108.0, "10th_percentile": 108.0, "90th_percentile": 108.0 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 108.0, "10th_percentile": 108.0, "90th_percentile": 108.0 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 120.87, "standard_charge_algorithm": "Case rate ($120.87). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "160", "median_amount": 35.47, "10th_percentile": 35.47, "90th_percentile": 35.47 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 61.75, "standard_charge_algorithm": "Fee schedule rate ($61.75).", "count": "197", "median_amount": 32.72, "10th_percentile": 32.72, "90th_percentile": 32.72 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 61.75, "standard_charge_algorithm": "Fee schedule rate ($61.75).", "count": "273", "median_amount": 64.38, "10th_percentile": 61.75, "90th_percentile": 64.38 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "414", "median_amount": 36.89, "10th_percentile": 34.34, "90th_percentile": 36.89 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "19", "median_amount": 35.47, "10th_percentile": 35.47, "90th_percentile": 35.47 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1270", "median_amount": 35.47, "10th_percentile": 35.47, "90th_percentile": 35.47 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "2773", "median_amount": 35.47, "10th_percentile": 35.47, "90th_percentile": 35.47 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "33", "median_amount": 36.89, "10th_percentile": 36.89, "90th_percentile": 36.89 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 36.97, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "219", "median_amount": 36.53, "10th_percentile": 34.01, "90th_percentile": 36.53 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 35.89, "standard_charge_algorithm": "APC Price ($35.89). The procedure is conditionally packaged with other services, and it is only paid if it is the highest rate for the service date. If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 35.47, "10th_percentile": 35.47, "90th_percentile": 35.47 } ], "minimum": 35.89, "maximum": 120.87, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Tte W/Doppler Complete - Tte Complete", "code_information": [ { "code": "CASE-93306", "type": "LOCAL" }, { "code": "93306", "type": "CPT" }, { "code": "483", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 622.96, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "382", "median_amount": 1228.13, "10th_percentile": 1228.13, "90th_percentile": 1325.28 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 542.41, "10th_percentile": 542.41, "90th_percentile": 542.41 }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "368", "median_amount": 1245.93, "10th_percentile": 1245.93, "90th_percentile": 1344.48 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 558.25, "standard_charge_algorithm": "APC Rate ($558.25). Final payment is multiplied by 229.17%.", "count": "71", "median_amount": 1288.22, "10th_percentile": 1023.75, "90th_percentile": 1288.22 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "1 through 10", "median_amount": 214.8, "10th_percentile": 107.4, "90th_percentile": 521.55 }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 558.25, "standard_charge_algorithm": "APC Rate ($558.25). Final payment is multiplied by 229.17%.", "count": "1028", "median_amount": 1288.22, "10th_percentile": 1206.07, "90th_percentile": 1288.22 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "53", "median_amount": 678.02, "10th_percentile": 627.93, "90th_percentile": 678.02 }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "14", "median_amount": 488.18, "10th_percentile": 475.99, "90th_percentile": 488.18 }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "1 through 10", "median_amount": 1227.51, "10th_percentile": 1227.51, "90th_percentile": 1227.51 }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 735.74, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "314", "median_amount": 730.17, "10th_percentile": 730.17, "90th_percentile": 730.17 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 1781.02, "standard_charge_algorithm": "Case rate ($1,781.02). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "20", "median_amount": 537.2, "10th_percentile": 537.2, "90th_percentile": 1121.34 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "13", "median_amount": 943.35, "10th_percentile": 836.55, "90th_percentile": 1067.94 }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "74", "median_amount": 444.98, "10th_percentile": 444.98, "90th_percentile": 444.98 }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "1 through 10", "median_amount": 1147.42, "10th_percentile": 531.32, "90th_percentile": 1147.42 }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 1313.81, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "1 through 10", "median_amount": 1303.88, "10th_percentile": 1303.88, "90th_percentile": 1303.88 }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "62", "median_amount": 521.55, "10th_percentile": 521.55, "90th_percentile": 521.55 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "1 through 10", "median_amount": 730.17, "10th_percentile": 676.23, "90th_percentile": 730.17 }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "1 through 10", "median_amount": 730.17, "10th_percentile": 676.23, "90th_percentile": 730.17 }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1051.05, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "18", "median_amount": 943.35, "10th_percentile": 943.35, "90th_percentile": 943.35 }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "26", "median_amount": 836.55, "10th_percentile": 836.55, "90th_percentile": 836.55 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "14", "median_amount": 772.78, "10th_percentile": 772.78, "90th_percentile": 772.78 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_algorithm": "If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "14", "median_amount": 772.78, "10th_percentile": 772.78, "90th_percentile": 772.78 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "18", "median_amount": 772.78, "10th_percentile": 772.78, "90th_percentile": 1779.9 }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "1 through 10", "median_amount": 772.78, "10th_percentile": 725.56, "90th_percentile": 772.78 }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "267", "median_amount": 521.55, "10th_percentile": 521.55, "90th_percentile": 521.55 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 102.2, "standard_charge_algorithm": "Fee schedule rate ($102.20).", "count": "362", "median_amount": 481.08, "10th_percentile": 445.54, "90th_percentile": 891.08 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 102.2, "standard_charge_algorithm": "Fee schedule rate ($102.20).", "count": "347", "median_amount": 107.4, "10th_percentile": 102.2, "90th_percentile": 107.4 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "318", "median_amount": 542.41, "10th_percentile": 502.34, "90th_percentile": 542.41 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "33", "median_amount": 521.55, "10th_percentile": 483.02, "90th_percentile": 521.55 }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1280", "median_amount": 521.55, "10th_percentile": 521.55, "90th_percentile": 521.55 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "3847", "median_amount": 521.55, "10th_percentile": 521.55, "90th_percentile": 521.55 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "34", "median_amount": 542.41, "10th_percentile": 542.41, "90th_percentile": 542.41 }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 541.29, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "136", "median_amount": 537.2, "10th_percentile": 497.51, "90th_percentile": 537.2 }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "1 through 10", "median_amount": 521.55, "10th_percentile": 521.55, "90th_percentile": 521.55 } ], "minimum": 102.2, "maximum": 1781.02, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC US Echo Tee", "code_information": [ { "code": "CASE-93312", "type": "LOCAL" }, { "code": "93312", "type": "CPT" }, { "code": "483", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1943.52, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 1275.04, "10th_percentile": 1275.04, "90th_percentile": 1275.04 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 1293.52, "10th_percentile": 1168.36, "90th_percentile": 1293.52 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 558.25, "standard_charge_algorithm": "APC Rate ($558.25). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 541.16, "10th_percentile": 507.97, "90th_percentile": 541.16 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 558.25, "standard_charge_algorithm": "APC Rate ($558.25). Final payment is multiplied by 229.17%.", "count": "17", "median_amount": 1288.22, "10th_percentile": 531.21, "90th_percentile": 1288.22 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 735.74, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "1 through 10", "median_amount": 730.17, "10th_percentile": 730.17, "90th_percentile": 730.17 }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 1842.2, "standard_charge_algorithm": "Case rate ($1,842.20). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1313.81, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "11", "median_amount": 521.55, "10th_percentile": 521.55, "90th_percentile": 521.55 }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1051.05, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 1131.98, "standard_charge_algorithm": "Fee schedule rate ($1,131.98).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "13", "median_amount": 521.55, "10th_percentile": 521.55, "90th_percentile": 521.55 }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 492.05, "standard_charge_algorithm": "Fee schedule rate ($492.05).", "count": "11", "median_amount": 1317.45, "10th_percentile": 445.54, "90th_percentile": 1323.84 }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 492.05, "standard_charge_algorithm": "Fee schedule rate ($492.05).", "count": "11", "median_amount": 488.27, "10th_percentile": 439.15, "90th_percentile": 488.27 }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "13", "median_amount": 542.41, "10th_percentile": 542.41, "90th_percentile": 542.41 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "56", "median_amount": 521.55, "10th_percentile": 521.55, "90th_percentile": 521.55 }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "166", "median_amount": 521.55, "10th_percentile": 521.55, "90th_percentile": 521.55 }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 541.29, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 492.05, "maximum": 1842.2, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Doppler Echo Exam Heart - Complete W/ Doppler", "code_information": [ { "code": "CASE-93320", "type": "LOCAL" }, { "code": "93320", "type": "CPT" }, { "code": "483", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1903.1, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 357.39, "10th_percentile": 357.39, "90th_percentile": 357.39 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 362.57, "10th_percentile": 362.57, "90th_percentile": 362.57 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 558.25, "standard_charge_algorithm": "APC Rate ($558.25). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 151.68, "10th_percentile": 142.38, "90th_percentile": 151.68 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 558.25, "standard_charge_algorithm": "APC Rate ($558.25). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 162.43, "10th_percentile": 143.49, "90th_percentile": 517.95 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 735.74, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 678.84, "standard_charge_algorithm": "Case rate ($678.84). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1313.81, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1051.05, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 355.45, "standard_charge_algorithm": "Fee schedule rate ($355.45).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 492.05, "standard_charge_algorithm": "Fee schedule rate ($492.05).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 492.05, "standard_charge_algorithm": "Fee schedule rate ($492.05).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "1 through 10", "median_amount": 592.62, "10th_percentile": 592.62, "90th_percentile": 592.62 }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "GLOBAL MEDICARE ADVANTAGE", "plan_name": "GLOBAL HEALTH MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 541.29, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 103%.", "count": "0" }, { "payer_name": "AARP MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" } ], "minimum": 355.45, "maximum": 1313.81, "additional_generic_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." } ] }, { "description": "HC Doppler Color Flow Velocity Map", "code_information": [ { "code": "CASE-93325", "type": "LOCAL" }, { "code": "93325", "type": "CPT" }, { "code": "483", "type": "RC" } ], "standard_charges": [ { "setting": "outpatient", "discounted_cash": 1731.33, "payers_information": [ { "payer_name": "AETNA", "plan_name": "AETNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "1 through 10", "median_amount": 937.5, "10th_percentile": 937.5, "90th_percentile": 937.5 }, { "payer_name": "AETNA", "plan_name": "AETNA HMO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "standard_charge_algorithm": "69% of billed.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "CIGNA", "plan_name": "CIGNA", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "1 through 10", "median_amount": 951.09, "10th_percentile": 859.06, "90th_percentile": 951.09 }, { "payer_name": "COVENTRY", "plan_name": "COVENTRY", "methodology": "percent of total billed charges", "standard_charge_percentage": 59.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "GEHA", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 558.25, "standard_charge_algorithm": "APC Rate ($558.25). Final payment is multiplied by 229.17%.", "count": "1 through 10", "median_amount": 397.9, "10th_percentile": 373.5, "90th_percentile": 397.9 }, { "payer_name": "HUMANA", "plan_name": "HUMANA CHOICECARE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UNITED HEALTHCARE", "plan_name": "UNITED HEALTHCARE", "methodology": "fee schedule", "standard_charge_dollar": 558.25, "standard_charge_algorithm": "APC Rate ($558.25). Final payment is multiplied by 229.17%.", "count": "11", "median_amount": 376.41, "10th_percentile": 189.32, "90th_percentile": 581.11 }, { "payer_name": "PHCS", "plan_name": "PHCS", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "VETERANS EVAL SERVICES", "plan_name": "VETERANS EVALUATION SERVICES", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "MANHATTAN LIFE", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHSCOPE", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AMBETTER MAGNOLIA", "plan_name": "AMBETTER", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 735.74, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 140%.", "count": "0" }, { "payer_name": "GLOBAL HEALTH", "plan_name": "GLOBAL HEALTH COMMERCIAL", "methodology": "fee schedule", "standard_charge_dollar": 1354.64, "standard_charge_algorithm": "Case rate ($1,354.64). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 63%, 999 procedures at 31.5%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 60.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HEALTHCARE HIGHWAYS", "plan_name": "HEALTHCARE HIGHWAYS", "methodology": "percent of total billed charges", "standard_charge_percentage": 25.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "OSCAR INSURANCE COMPANY", "plan_name": "MERCY NETWORK", "methodology": "percent of total billed charges", "standard_charge_percentage": 46.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "THE KEMPTON GROUP", "plan_name": "KEMPTON GROUP", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1313.81, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 250%.", "count": "0" }, { "payer_name": "VA CCN", "plan_name": "VA CCN", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "PREFERRED COMMUNITY CHOICE", "plan_name": "PREFERRED COMMUNITY CHOICE PPO", "methodology": "percent of total billed charges", "standard_charge_percentage": 76.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "SANA BENEFITS", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "UFCW", "plan_name": "HEALTHSMART ACCEL", "methodology": "percent of total billed charges", "standard_charge_percentage": 65.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "FIRST HEALTH NETWORK", "plan_name": "FIRST HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 69.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "MULTIPLAN", "plan_name": "MULTIPLAN", "methodology": "percent of total billed charges", "standard_charge_percentage": 90.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "CCHMO STATE HEALTH", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 1051.05, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 200%.", "count": "0" }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE LIFE AND HEALTH", "methodology": "percent of total billed charges", "standard_charge_percentage": 70.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "COMMUNITY CARE", "plan_name": "COMMUNITY CARE HMO", "methodology": "fee schedule", "standard_charge_dollar": 191.79, "standard_charge_algorithm": "Fee schedule rate ($191.79).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA HOBBY LOBBY HCH", "plan_name": "EmployerAdvocates - HOBBY LOBBY", "methodology": "percent of total billed charges", "standard_charge_percentage": 53.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "WEBTPA CHICKASAW NATION HCH", "plan_name": "EmployerAdvocates - CHICKASAW NATION", "methodology": "percent of total billed charges", "standard_charge_percentage": 47.0, "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE CHOICE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PLAN SELECT 65", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE TRADITIONAL", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE PREFERRED", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE ADVANTAGE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "BLUE LINCS", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS IN STATE", "plan_name": "MYBLUE", "methodology": "fee schedule", "standard_charge_dollar": 811.58, "standard_charge_algorithm": "Case rate ($811.58). The procedures on the claim are sorted highest to lowest by case rate and reimbursed, rounded down to the nearest cent, based on the following tiered percentages: 1 procedures at 100%, 1 procedures at 50%, 99999 procedures at 25%.", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "BCBS - MEDICARE ADVANTAGE", "plan_name": "BLUE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "AETNA BETTER HEALTH OF OK", "plan_name": "AETNA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 492.05, "standard_charge_algorithm": "Fee schedule rate ($492.05).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "HUMANA HEALTHY HORIZONS IN OK", "plan_name": "HUMANA MEDICAID", "methodology": "fee schedule", "standard_charge_dollar": 492.05, "standard_charge_algorithm": "Fee schedule rate ($492.05).", "count": "0", "additional_payer_notes": "Zero final payments for the item or service in the 15 months prior to posting the file." }, { "payer_name": "AETNA MEDICARE ADVANTAGE", "plan_name": "AETNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement. Final payment is multiplied by 104%.", "count": "0" }, { "payer_name": "CIGNA MEDICARE ADVANTAGE", "plan_name": "CIGNA MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "HUMANA MEDICARE ADVANTAGE", "plan_name": "HUMANA CHOICECARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "UNITED HEALTHCARE MEDICARE", "plan_name": "UNITED HEALTHCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the file.", "standard_charge_dollar": 525.53, "standard_charge_algorithm": "APC Price ($525.53). If cost exceeds the threshold, the outlier payment is added to the expected reimbursement. Cost is calculated as the billed amount * the cost-to-charge ratio (0.244). The threshold is calculated as the maximum of the outlier multiplier threshold and the fixed threshold. The outlier multiplier threshold is the outlier multiplier factor (1.75) * adjusted APC rate for the line, and the fixed threshold is the outlier fixed-dollar threshold ($6,225) + adjusted APC rate for the line. If the cost is greater than the comparative threshold, then the outlier payment is calculated as 0.5 * (cost - outlier multiplier threshold) and is added to the expected reimbursement.", "count": "0" }, { "payer_name": "WELLCARE MEDICARE", "plan_name": "WELLCARE MEDICARE ADVANTAGE", "methodology": "other", "additional_payer_notes": "OPPS APC Zero final payments for the item or service in the 15 months prior to posting the f