Allowable Schedule Worksheet Reference

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You can use this page to gather all the information you need to create an athenaOne allowable schedule, along with its terms and conditions. You need an allowable schedule to take advantage of the athenaOne enhanced allowable amount estimation capabilities.

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Allowable Schedule Worksheet


Payer:
Product(s):
Insurance Packages In/Excluded:

Reimbursement Methods section
Data Element Name	Type of Field	Brief Description
Allowable Schedules page
Name:	Free text	Name your allowable schedule according to your practice's naming convention.
Effective Date:	Date	The effective date of the allowable schedule.
Evergreen?	Radio button Yes or No	Evergreen clauses are very common in payer agreements. Clicking Yes means that your contract automatically renews each year, if neither party provides termination or notice of change within the contract's notice period.

Expiration Date:	Date	The end date of the allowable schedule terms.
Notice Period (in days):	Number of days	The number of days, as specified in your contract, that you must notify the payer in advance, if you plan to terminate your contract.
Notice Period Date:	Date	The date by which you must notify the payer that you plan to terminate or request changes to your contract. To calculate this date, athenaOne assumes an anniversary date of one year and subtracts the number of notice period days. Note: athenaOne automatically updates this date each year, if no changes are made to the allowable schedule following the assumed anniversary date.
Allowable Category: Global / Local	Multi-select list of athenaOne global allowable category code set or client's local allowable category code set	Groups of a payer's products and plans covered by the allowable schedule.
Medical Group:	Multi-select list of medical groups	Select the medical group(s) covered by the allowable schedule.
Department:	Multi-select list of the athenaOne department code set	Select the service department(s) covered by the allowable schedule.
Choose provider(s) by name:	Multi-select list of the athenaOne provider code set	Select the Individual provider(s) covered by the allowable schedule.
Choose provider(s) by specialty:	Multi-select list of the athenaOne specialty code set	Filter the list of providers by specialty covered by the allowable schedule.
Conditions section Establish the conditions under which the following reimbursement method and adjustments should be applied.
Service Category:	Radio button to choose All, Selected, or All except. If you choose Selected or All except, you can then choose either global or local procedure code groups. Based on selection, athenaOne displays drop-down lists of the selected code set.	Global service categories reference the subsections of the AMA CPT code book. Local service categories reference the procedure code ranges and/or unique CPT codes created using the procedure code groups table. Note: This is a user-defined code set.
Place of Service:	Radio buttons for All, Selected, All except, All Facility or All Non-Facility. If you click Selected or All except, you can specify individual or multiple places of service from the drop-down. If you click All Facility or All Non-Facility, athenaOne will automatically select the appropriate code set for you.	Use industry-standard place of service code set to define any adjustments made based on place of service. Sample place of service scenario: "When these services [referring to E&M] are furnished in hospital outpatient setting, reimbursement is limited to 60% of the base rate." The base rate in this case is 100% of the Medicaid fee schedule or 105% of the Medicaid fee schedule for PCPs. This adjustment would then be applied to all charges submitted where the place of service code = 22 Outpatient Hospital.
Specialty:	Multi-select list of the athenaOne specialty code set
Provider Type:	Multi-select list of the athenaOne provider credentials code set	Is the contract or any of its terms dependent on the provider's credentials? If so, list all provider types covered by this set of terms and conditions. Note: Provider type code set values include but are not limited to: MD, CRNA, LICSW, PA, CNM, etc. Provider type is also referred to as a provider credential.
Taxonomy:	Multi-select list of industry-standard taxonomy code set	Is the contract or any of its terms dependent on the provider's specialty? If so, list all taxonomy codes covered by this set of terms and conditions.
Which reimbursement method is used to price an adjudicated claim?	Radio button	Click the option to the left of the reimbursement method that describes the calculation that should be used to estimate an allowed amount.
None	Reimbursement Method option	Indicates reimbursement is based on a fixed flat rate fee per procedure code.
Based on Medicare Expected	Reimbursement Method option	Indicates reimbursement is based on CMS's RBRVS calculation. This payment methodology has three components: a relative value for each procedure, a geographic adjustment factor, and a dollar conversion factor. Conversion factors used in the calculation can be modified in the Reimbursement Methods section. Please see National Physician Allowable Schedule Parameters section (below)
Based on global allowable schedule	Reimbursement Method option	Indicates reimbursement is based on a rate schedule loaded and maintained by athenaOne. The beta release includes global allowable schedules for the following state Medicaids: CA, CO, FL, GA, IL, MA, OH, and TX.
Based on percentage of billed	Reimbursement Method option	Indicates reimbursement is based on a percentage of the provider's billed amount. The actual percentage to be used is entered below in the Adjustments section in the Adjust to Percent field.
National Physician Allowable Schedule Parameters section Complete this section with values to be used when estimating an allowed amount based on RBRVS.
Medicare allowable schedule year	Drop-down list	The calendar year's values to be used to calculate estimated allowed amounts. If calculation should be based on the date of service, select (date of charge) in the drop-down list.
Medicare allowable schedule location	Drop-down list of 89 Medicare GPCI localities	Which GPCI location should be used to calculate estimated allowed amounts? If calculation should be based on the actual location of service, select (based on service department(s) location).
Percent of Medicare allowable:	Percentage	What percentage of the Medicare allowed amount should be reimbursed?
RVU conversion factor:	Dollar amount	What conversion factor should be used to calculate the estimated allowed amount using the RBRVS method?
Create based on non-facility schedule?	Drop-down list	Is reimbursement fixed to pay at the facility or non-facility rate? Or, is it based on the actual service location?
Create based on participating provider?	Drop-down list	Does the allowed amount assume the provider is par or non-par?
Create based on accept assignment schedule?	Drop-down list	Does the provider accept assignment under the terms of this contract?
National DME Allowable Schedule Parameters section Complete this section with values to be used when estimating an allowed amount for durable medical equipment, using the Medicare fee schedule payment methodology for DME, prosthetics, and orthotics.
Percent of Medicare DME allowable:	Percentage	Percentage of CMS DME fee schedule paid under the contract.
Medicare DME state:	Drop-down list	The state that DME reimbursement is based on.
Medicare DME allowable schedule period:	Drop-down list	The release of CMS's DME fee schedule is reimbursement based on.
Create based on participating provider?	Drop-down list	Does the allowed amount assume the provider is par or non-par?
Create based on accept assignment schedule?	Drop-down list	Does the provider accept assignment under the terms of this contract? Note: Non-participating physicians may elect to accept assignment on claims. Non-par unassigned claims are subject to the "limiting charge" provision.
Anesthesia Reimbursement Method section
Use anesthesia reimbursement	Checkbox	Check this box to use the anesthesia terms and conditions.
Conversion factor	$	Specify the conversion factor in dollars.
Time Unit	Drop-down list	Select the time unit method to use.
Round	Drop-down list	Select the rounding method to use.
Physical Status Modifiers	Checkbox	Check this box to use physical status modifiers.
P3	Numeric field	Specify the base units.
P4	Numeric field	Specify the base units.
P5	Numeric field	Specify the base units.
Adjustments section
Adjust to Percent:	Percentage	If "Based on percentage of billed" is selected as the reimbursement method, select the percentage of the billed amount that is allowed. Otherwise, use this field to apply a reduction to the estimated allowed amount.
Subject to lesser of billed or allowed:	Radio Button Yes or No	Does the payer's contract include a provision to compare their allowed amount to the billed amount and pay the lesser of the two?
Multiple Procedure:	Radio Button Yes or No	This occurs when two or more surgical services are provided to the same patient, typically by the same provider, on the same day. Typically, some reduction is applied for all but the highest paying procedure. Describe the payer's payment adjustment policy as it relates to multiple procedures using the fields below. Note: athenaOne populates lines 1-5 below with the standard CMS multiple procedure reduction adjustments.
First:	Numeric field	The percentage of line 1 to be paid on a multi-line surgical claim.
Second:	Numeric field	The percentage of line 2 to be paid on a multi-line surgical claim.
Third:	Numeric field	The percentage of line 3 to be paid on a multi-line surgical claim.
Fourth:	Numeric field	The percentage of line 4 to be paid on a multi-line surgical claim.
Fifth:	Numeric field	The percentage of line 5 to be paid on a multi-line surgical claim.
Modifiers:	Radio Button Yes or No	A physician or facility reports a modifier on a claim to indicate that a service provided to a patient has been altered by some circumstance. Modifiers may increase (-22) or decrease (-52) the allowed amount. Use these fields to record the modifier and the impact, expressed as a percentage, it will have on the allowed amount. You can either use the default modifiers and standard CMS percentages, or add your own. You can also delete any standard modifiers.
50	Percentage
51	Percentage
80	Percentage
81	Percentage
82	Percentage
AS	Percentage
62	Percentage