Allowable Schedule Terms and Conditions

1. Display the Allowable Schedules page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Fee and Allowable Schedules, click Allowable Schedules.
2. Click the update link next to the schedule's name.
   The Update Allowable Schedule view appears.
3. Click the Add Terms and Conditions link.
   The Allowable Schedule Terms and Conditions page appears.
4. Under the Reimbursement Methods heading, select Based on global allowable schedule.
5. Select the appropriate state allowable schedule from the list.
6. Click Save.

1. Display the Allowable Schedules page: On the Main Menu, click Settings > Billing. In the left menu, under Practice Links — Fee and Allowable Schedules, click Allowable Schedules.
2. Click update for an existing allowable schedule listed under the Allowable Schedules heading.
3. Under the Terms and Conditions heading, click Add Terms and Conditions.
   The Allowable Schedule Terms and Conditions page appears.

Specify the conditions for payment by service category, facility, place of service, specialty, provider type, or taxonomy

4. Under the Conditions heading, click Selected or All except for the category that you need to specify in the contract. Then select Global or Local.
5. Select the relevant items from the list. Hold down the Ctrl key to select multiple items from the list.
6. Repeat steps 4 and 5 for each category that you need to specify.

Specify the reimbursement methods that apply to claims adjudicated under your contract

7. Under the Reimbursement Methods heading, select the option for the contract's reimbursement method.
8. If you click Based on Medicare expected or Based on global allowable schedule, additional fields appear. Enter the relevant data according to the terms of the contract.

For contracts covering anesthesia claims

9. Under the Anesthesia Reimbursement Method heading, select the Use anesthesia reimbursement option. Additional fields appear.
10. Conversion factor — Enter the conversion factor (in dollars) that this payer will reimburse per anesthesia unit for this contract. Conversion factors vary by payer, state, and contracted rate. For example, Medicare NC's conversion factor is $19.23. 
11. Time unit — Select the method this payer uses to calculate time units when adjudicating an anesthesia claim: 15 minutes, 12 minutes, 10 minutes, or 1 minute. For example, Medicare calculates time units in 15-minute increments, so they divide the total minutes reported on a claim by 15.
12. Round — Select the rounding method this payer uses when the minutes are divided by the specified time unit. Select Up to, To nearest, or Down to, then select whole minute or tenth of minute. For example, Medicare reimburses at 15-minute increments and rounds to the nearest tenth of a minute, so a service that lasted 85 minutes would be adjudicated by Medicare as 5.7 time units:
    • 85 total minutes divided by 15-minute time unit = 5.667
    • 5.667 rounded to the nearest tenth of a minute = 5.7 time units
13. Physical status modifiers — Select the Reimburse Physical Status Modifiers option if this payer reimburses additional units for physical status modifiers, then specify the number of additional base units reimbursed for modifiers P3, P4, and P5. Medicare does not reimburse additional units for physical status modifiers.

Note: Anesthesia practices can also specify adjustments based on modifiers in the Adjustments section (described below). This is important for anesthesia practices that bill for medically directed anesthesia services between an anesthesiologist and a CRNA.

• Click the Yes option in the Modifiers field.
• Enter the modifier and the expected payment adjustment for charges with that modifier. For example, most payers reimburse 50% for modifiers QY, QK, and QX. If this applies to your allowable schedule, enter these modifiers in the Modifiers column and 50 in the Percent column.

Specify any adjustments that apply to your contract

 

Note: Anesthesia practices can also specify adjustments based on modifiers in the Adjustments section. This is important for anesthesia practices that bill for medically directed anesthesia services between an anesthesiologist and a CRNA.

15. Adjust to percent — Use this field to define the allowable amount as a percentage of billed charges or to include an additional adjustment to the estimated paid amount.
16. Subject to lesser of billed or allowed — Use this field if your contract specifies that procedures will be paid at the lesser of billed charges or allowed amount.
17. Multiple procedure — Select Yes if your contract defines specific percentages for multiple procedure reimbursement and enter the appropriate percentage amounts.
18. Modifiers — Select Yes if your contract defines specific percentages for modifier reimbursement and enter the appropriate percentage amounts.

Note: When you click the Multiple procedure or Modifiers option, athenaOne pre-populates the fields with the standard Medicare amounts. Be sure to edit these fields as necessary, based on your payer's payment policies.

 

Adjustments are sometimes referred to as payment policies or payment adjustments. Common adjustments include:

• A fixed percentage reduction to the estimated allowed amount
• A flag to indicate whether or not the allowed amount will be compared to the billed amount, and then paid at the lesser of the two amounts
• Multiple procedure reduction adjustments
• Modifier adjustments