HMO - Max Fee Rate Extract File Layout
Field
Data Type
Max Length*
Max Recursions
Description
Contract Code
Character
5
1
Code that is used to uniquely identify a Provider Contract.
Contract Name
20
Provider Contract Name.
Procedure Code
HCPCS or CPT Procedure Code.
BC+ BM/Core Billing Indicator
Indicates whether the service is billable for the Benchmark and/or Core Plans. N = Not a billable Benchmark or Core service. Y = Billable Benchmark and Core service. B = Billable Benchmark service only. C = Billable Core service only.
BP List
7
Unlimited
List of Benefit Plans (BP) that are included or excluded from the reimbursement rule, if applicable.� For example:
I~MCD = Includes Medicaid
I~BCSP = Includes BadgerCare Plus (BC+) Standard
E~BCBP = Excludes BC+ Benchmark
I~BCBEE;I~BCBPD = Includes BC+ Benchmark Express Enrollment for Pregnant Women and BC+ Benchmark Plan with Dental
PT/PS List
8
List of Provider Types (PT) and Provider Specialties (PS) that are included or excluded from the reimbursement rule, if applicable.� For example:
I~77/000 = Includes Providers with PT 77, regardless of specialty
E~77/010 = Excludes Providers with PT 77 and PS 010
I~16/160;I~16/161 = Includes Providers with PT 16 and PS 160 or 161
Age Min-Max
11
Reimbursement rule age restrictions (minimum and maximum).� Format is 9999 - 9999.
For example:
0 - 18
19 - 999
0 - 20
21 - 999
Note:� While format allows up to a four digit age, in practice, standard is to use 999 as the default max age.� There may be exceptions.
Pricing Indicator
6
Code that identifies the reimbursement/pricing methodology:� ANESTH, MAXFEE or SYSMAN (manually priced).
Rate Type
3
Code that identifies the type of rate.
Max Fee Modifiers 1-4
2
4
Max Fee Modifiers, if applicable.
Rate
Number
10
Max fee rate for the procedure/service. Format is 9999999.99.
RVS Units
Applicable relative value unit (RVU). Format is 999.9.
BAF Codes
Benefit Adjustment Factor (BAF) codes, if applicable.� For example:
120 = Adjustment of 120%
20 = Adjustment of 20%
HPSA120 = Adjustment of 120% (for HPSA Incentive)
Effective Date
Date
First date of service the rate is effective. Format is CCYYMMDD.
End Date
Last date of service the rate is effective. Format is CCYYMMDD.
File Format:� Text Delimited
Field Delimiter: Vertical Bar -> |
Sub-field Delimiter for recursive fields: Semi-colon -> ;
* Max Data Length per field recursion including special characters such as decimals.�
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