Understanding External References and Modifiers in Provider Networks
Exploring the intricate details of external references, providers, and negotiated rates within provider networks. Learn about in-network files, iterative development, and the nuances of Medicare plans. Uncover the complexities of provider group IDs, negotiated prices, and in-network locations.
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(Recap of webinar #4) External References And Modifiers
External References Two Types External Provider Networks Other External Valid In-network Files
{ "plan_name": "medicare", Provider Networks/Groups "provider_references": [{ "provider_group_id": 1, Iterative Development "provider_groups": [{ { "npi": [2222222222], "tin":{ "billing_code": "27447", "type": "ein", "negotiated_rates": [{ "value": "11-1111111" "provider_groups": [{ } "npi": [2222222222], }] "tin":{ } { "type": "ein", "value": "11-1111111" "billing_code": "27447", } "negotiated_rates": [{ }], "provider_references": [1], "negotiated_prices": [{ "negotiated_prices": [{ "negotiated_type": "negotiated", "negotiated_type": "negotiated", "negotiated_rate": 123.45 "negotiated_rate": 123.45 }] }] } }
// in-network file Provider Networks/Groups { Iterative Development "plan_name": "medicare", "provider_references": [{ // in-network file "provider_group_id": 1, { "location": "https://www.cms.gov/providers.json" }] "plan_name": "medicare", } "provider_references": [{ // in-network negotiated rate object "provider_group_id": 1, { "provider_groups": [{ "npi": [2222222222], "billing_code": "27447", "tin":{ "negotiated_rates": [{ "type": "ein", "provider_references": [1], "value": "11-1111111" "negotiated_prices": [{ } "negotiated_type": "negotiated", }] "negotiated_rate": 123.45 } }] }
// in-network file Provider Networks/Groups { Iterative Development "plan_name": "medicare", "provider_references": [{ "provider_group_id": 1, // in-network file "location": "https://www.cms.gov/providers.json" { }] } "plan_name": "medicare", "provider_references": [{ "provider_group_id": 1, // URL to providers.json "provider_groups": [{ { "npi": [2222222222], "provider_groups": [{ "tin":{ "npi": [2222222222], "type": "ein", "tin":{ "value": "11-1111111" "type": "ein", } "value": "11-1111111" }] } } }] }
Implementation Example 3 things needed to use external provider networks. Provider Reference Location Defined External Provider Group/Network File Reference ID in Negotiated Rate Object
NEW TABLE OF CONTENTS FILE 2020-08-07_cms_index.json { "in_network_file": { "description": "In-network file", "file": "https://www.cms.com/files/in-network-file-123134.json" } "reporting_entity_name": "cms", "reporting_entity_type": "cms", "reporting_structure":[{ "reporting_plans": [{ "plan_name": "medicare", "plan_id_type": "hios", "plan_id": "11111111111", "plan_market_type": "individual" "in_network_file": [{ "description": "In-network file", "file": "https://www.cms.com/files/in-network-file-123134.json" }] },{ "plan_name": "medicaid", "plan_id_type": "hios", "plan_id": "0000000000", "plan_market_type": "individual" "in_network_file": [{ "description": "In-network file", "file": "https://www.cms.com/files/in-network-file-123134.json" },{ "description": "behavioral health in-network shared file", "file": "https://www.some_site.com/files/behavioral-health-0000.json" }] }], "in_network_file": { "description": "In-network file", "file": "https://www.cms.com/files/in-network-file- 123134.json" } }]
External In-Network Files Must be valid (comply with the in-network schema) in-network files
Implementation example Pull Request Details Allowed Amounts File: Allowed Amounts Object In-Network File: Negotiated Price Object https://github.com/CMSgov/price-transparency-guide/blob/develop/examples/in- network-rates/in-network-rates-fee-for-service-single-plan-sample.json#L35-L68
(Todays Discussion) New Negotiation Types, Custom Billing Code, and Additional Information Text Field
New Negotiation Types: Percentage Per Diem
Quick review of existing negotiation types: Negotiated: If applicable, the negotiated rate, reflected as a dollar amount, for each covered item or service under the plan or coverage that the plan or issuer has contractually agreed to pay an in-network provider Derived: If applicable, the price that a plan or issuer assigns to an item or service for the purpose of internal accounting, reconciliation with providers or submitting data in accordance with the requirements of 45 CFR 153.710(c) Fee Schedule: If applicable, the rate for a covered item or service from a particular in-network provider, or providers that a group health plan or health insurance issuer uses to determine a participant s, beneficiary s, or enrollee s cost-sharing liability for the item or service, when that rate is different from the negotiated rate. More information can be found on Github
Newly added negotiation types: Percentage: If applicable, the negotiated percentage value for a covered item or service from a particular in-network provider for a percentage of billed charges arrangement. Per Diem: If applicable, the per diem daily rate, reflected as a dollar amount, for each covered item or service under the plan or coverage that the plan or issuer has contractually agreed to pay an in-network provider. More information can be found on Github
Percentage of billed charges An example for a service that is contracted with a 35.7% of billed charges for the item or service "negotiated_prices": [{ "negotiated_type": "percentage", "negotiated_rate": 35.7, "expiration_date": "2022-01-01" }] } Note: the percentage should be reflected as a whole number. Github Pull Request
Percentage of billed charges Looking ahead to possible percentage of billed charges attributes additions While adding the percentage type allows for easily and accurately reflecting negotiated rates for these types of arrangements, there are additional attributes that may help provide more information for percentage of bill negotiations. relative priority of provision - a single number (usually 1-999) that reflects the priority of the negotiated arrangement to others. not-to-exceed thresholds - a single dollar value that is the maximum (ceiling value) paid in a percentage of bill arrangement. hurdle thresholds - a single dollar threshold number and a corresponding percentage number if charges surpass the threshold.
Percentage of billed charges Looking ahead to possible percentage of billed charges attributes implementation Scenario: Highest priority of a percentage of bill at 35.7%, that drops to 10.5% after $1000 and is not to exceed $1,500 Potential Future Implementation Current Implementation "negotiated_prices": [{ "negotiated_prices": [{ "negotiated_type": "percentage", "negotiated_type": "percentage", "negotiated_rate": 35.7, "negotiated_rate": 35.7, "expiration_date": "2022-01-01" "expiration_date": "2022-01-01", }] "percentage_priority": 1, } "percentage_exceed_limit": 1500, "percentage_charge_threshold": { "hurdle": 1000, "percentage_charge": 10.5 } }] }
Per Diem An example for a service that has a daily negotiated rate of $1000. "negotiated_prices": [{ "negotiated_type": "per diem", "negotiated_rate": 1000, "expiration_date": "2022-01-01" }] } Github Pull Request
Custom Billing Code Implementation Example Pull Request Details In-Network File Documentation New billing_code_type: CSTM-ALL This value represents all possible coding types under the contractual arrangement New billing_code: CSTM-00 Represents all possible billing_code values for the defined billing_code_type Why? Intended to reduce file size.
{ "negotiation_arrangement": "ffs", Custom Billing Code Implementation Example "name": "All coding types", "billing_code_type": "CSTM-ALL", "billing_code_type_version": "2022", Scenario: Negotiated arrangement of 35.7% of bill for all inpatient and outpatient services "billing_code": "CSTM-00", "description": "All codes possible", "negotiated_rates": [{ "provider_groups": [{ "npi": [6666666666], NOTE: the billing_code_type_version would apply to the current plan's year. "tin":{ "type": "npi", "value": "6666666666" } }], "negotiated_prices": [{ "negotiated_type": "percentage", "negotiated_rate": 35.7, "expiration_date": "2022-01-01", }] }
{ "negotiation_arrangement": "ffs", Custom Billing Code Implementation Example "name": "All HCPCS codes", "billing_code_type": "HCPCS", "billing_code_type_version": "2022", Scenario: Negotiated arrangement of 35.7% of bill for all HCPCS codes "billing_code": "CSTM-00", "description": "All HCPCS codes possible", "negotiated_rates": [{ "provider_groups": [{ "npi": [6666666666], Looking ahead: Other custom codes that would help out reduce file size. Possible implementation for service_code "tin":{ "type": "npi", "value": "6666666666" } }], "negotiated_prices": [{ "negotiated_type": "percentage", "negotiated_rate": 35.7, "expiration_date": "2022-01-01", }] }
Additional Information Text Field Implementation Example Pull Request Details In-Network File Documentation New, optional additional_information string (text) attribute added to the Negotiated Price Object Documentation: The additional information text field can be used to provide context for negotiated arrangements that do not fit the existing schema format. Please open a Github discussion to ask a question about your situation if you plan to use this attribute. NOTE: CMS is not trying to be a gatekeeper on the usage of this attribute and opening a Github discussion is certainly optional, rather CMS wants to get a better idea on what negotiation scenarios required this attribute to help inform future schema iterations.
Additional Information Text Field Implementation Example Scenario: 35% of Billed Charges paid in addition to other negotiated rates for a listed individual billing code only, when the sum of the listed individual billing code claim lines is greater than $1000.00 Additional Information Implementation Current Implementation "negotiated_prices": [{ "negotiated_prices": [{ "negotiated_type": "percentage", "negotiated_type": "percentage", "negotiated_rate": 35, "negotiated_rate": 35, "expiration_date": "2022-01-01" "expiration_date": "2022-01-01", }] "additional_information": "paid in addition to other negotiated } rates for a listed individual billing code only, when the sum of the listed individual billing code claim lines is greater than $1000" }
Additional Information Text Field Implementation Example Scenario: service under a per diem arrangement that pays $1000 for the first 3 days and $750 each day thereafter. Additional Information Implementation "negotiated_prices": [{ Current Implementation "negotiated_type": "per diem", "negotiated_rate": 1000, "negotiated_prices": [{ "expiration_date": "2022-01-01", "negotiated_type": "per diem", "additional_information": "for the first 3 days", "negotiated_rate": 1000, },{ "expiration_date": "2022-01-01" "negotiated_type": "per diem", },{ "negotiated_rate": 750, "negotiated_type": "per diem", "expiration_date": "2022-01-01", "negotiated_rate": 750, "additional_information": "each day after the 3rd", "expiration_date": "2022-01-01" }] }] } }
