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Provider Fee Definition

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Manage provider fee definitions. These fees associate CPT or revenue codes with a provider.

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  • Retro Rate Adjudication will be triggered by setting the Expiration Date. It will also be triggered by making the code inactive as it forces you to set the dollar amount to "0". To accommodate services after the Expiration Date, create another fee definition with an Effective Date after the Expiration Date. This will effectively cancel out the Retro Rate Adjudication for those services as it will take into account the new fee definition.

Fee Definition

  1. In the Enter New Or Edit Existing Fee Definition field:

  • Select Enter New to create a provider fee definition.

  • Select Edit Existing to change provider fee definition information.

  1. In the Enter/Edit CPT Or Revenue Code Fee Information field:

  • Select CPT Service Code to manage CPT codes.

  • Select Revenue Code to manage revenue codes.

  1. In the Provider field, enter the provider name, and select.

  2. In the CPT Code field, select the CPT code (set up in the CPT Code Definition form).

  3. In the Revenue Code field, select the revenue code (set up in the Revenue Code Definition form).

  4. Click Select Fee Definition To Edit to display the Edit Provider Fee Definition screen. Select a provider fee definition, click Ok.

  5. Click Provider Fee Definition Report to generate a provider fee definition report that details provider fee definitions entered in this form.

  6. In the Effective Date and Expiration Date fields, enter the date the provider fee becomes active and inactive respectively.
    If the Funding Source, Plan, Performing Provider's License Type, and Authorized Level of Care fields are blank, all entities in these fields that are not associated with the CPT or revenue code will be associated to the provider fee.

  7. In the Member ID field, select the specific member to define fee definitions for, if desired.

  8. In the Funding Source field, enter the funding source name, and select.

  9. In the Plan field, select the benefit plan.

  10. In the Performing Provider's License Type field, select the license type.

  11. In the Authorized Level Of Care field, select the level of care.

  12. In the Amount field, enter the provider fee amount.

  13. In the Status field:

    • Select Active if the provider fee is active.
    • Select Inactive to make the provider fee inactive.

Ratios

The ratio fields allow the billed amount to change, based on a percentage of the total charge.

  1. In the Ratio of Cost to Charge field, enter the percentage of the total charge to be used for the allowed amount.
  2. In the Effective Ratio of Cost to Charge Percentage to Use field:
    • Select Default to use 100 percent of the cost.
    • Select None to use 0 percent of the cost.
    • Select Unique to enter an percent (Effective Ratio of Cost to Charge Percentage field).
  3. In the Allow Duplicate Services on the Same Day field, select Yes to allow duplicate

  4. Click Submit.