Provider Applications

Agreement, Medical Application (AGAG)

An Agreement represents an Managed Care Organization (MCO)’s contract with a provider (who can
be a Healthcare Facility, Individual Practice Association (IPA), Provider Group or Practitioner).
Agreements can vary from provider to provider, or can be shared by all providers in a network. It
contains information on how a contract has been negotiated with a provider. This includes
establishing rules for that provider’s inpatient and outpatient claims, setting up provisions for
discounts, risk-withhold stoploss and special pricing considerations and determining if profile pricing
exists.

Once the agreement is established, it is attached to a provider’s relationship row. While an

agreement is usually established to determine in-network benefits, it can also be used to price a
provider’s out of network claims via the non-participating provider relationship row.

The Multiple Surgery Outpatient Pricing Type:

This option is used to indicate when to price the first or primary surgery with a specific charge using a
multiple surgery percentage. This option allows an MCO to process surgical claims by rolling-up all
ancillary fees into one price for a surgery when multiple surgeries occur. With this option, an MCO
can roll specific ancillary charges into the fee for the first surgery identified by Facets, process the line
at a percentage (specified by the MCO) of the fee schedule multiplied by a surgery factor that is
specific to a facility, process ancillary charges that are not rolled-up using a percentage of the charges
and process the other surgeries on the claim with an allowable of 0.00. This option works in
conjunction with ASC pricing, and can also work with R& C pricing.

Using the Multiple Surgery Outpatient Pricing Type:

This value provides users with the ability to price the first or primary surgery identified with a price.
An MCO can identify the specific charge using the Multiple Surgery % checkbox to establish the
desired discount amount to be applied to the first or primary surgery. If the Multiple Surgery
Outpatient Pricing Type is chosen, the Multiple Surgery % field must be completed with a value
greater than zero in order to determine the discount. If a different Outpatient Pricing Type other than
“Multiple Surgery” has been established, the Multiple Surgery % field is not available.

 Payment Drag Section Tab: For providers linked to an agreement, this section tab indicates how often
claims should be processed for payment. Payment drag may be set at the Administrative Information-
level (AIAI) or at the agreement level. Drags established at the agreement level override those on the
AIAI.

 Related Prefixes Section Tab: This section tab identifies prefixes of different Medical Agreement
applications that have been attached to the agreement and will be referenced during Claims and/or
UM processing.

Page 1 of 5
  The Related Prefix ID’s may be shared among various agreements. The following Related Prefixes may
be attached to an agreement:

*Service Definition (AGSE) Stoploss (AGSL) Auto Room Type (AGRT)

Exclusions (AGPD) DRG Rules (AGRG) ASC Multiple Procedures (AGHI)

Prompt Payment Discount (AGPP) COB Rules (AGCB) Delegated Services - Claim (AGDC)

Inlier (AGIL) Procedure (AGIP) Delegated Service – UM (AGDU)

Modifier Pricing Rules (AGPC)

Note: The Service Definition is a required related prefix. The other prefixes are not required, but may
be added if they apply to the agreement. Each of the related prefixes will be explained in detail later
in this chapter, except for the COB Rules application, which is detailed in the “Agreement / Pricing
Profiles: Reference Guide” at the end of this chapter.

Related Prefixes:

The SEDF Product Component is the default Service Definition that is read to obtain pricing
information when the provider on the claim is found to be out-of-network.

Exclusions Application (AGPD)

This application lists services that are excluded from the normal agreement pricing, but are priced
using different pricing rules. Exclusions are not non-covered services, but services that require a
different pricing methodology. This Exclusions table allows services to be excluded or included in roll-
up and/or stoploss thresholds. In addition, you may apply a discount-off charges or allowable, or have
a service paid at a flat fee rate. Furthermore, the effective and termination dates allow you to create
new Exclusions prefixes when new generations of provider agreements are needed. This functionality
will also help during claims and UM processing because Facets will compare the effective and
termination dates set-up here with a line-item’s service dates. Facets will generate error messages if
the claim or UM line-item falls outside the range. The prefix created for this application gets attached
to the provider’s Agreement application in the Related Prefixes section tab.

ASC Multiple Procedures Application (AGHI)

The ASC Multiple Procedures application allows the user to designate parameters to be used when
pricing multiple ambulatory surgical procedures performed on the same day at a free-standing
Ambulatory Surgery Center (ASC) or outpatient department of a hospital. Rules may be established to
identify the primary procedure (based on billed charges or the allowable). The percentages at which
Facets prices ASC procedures subsequent to the primary procedure may also be set-up. In this way, a
user may vary percentage rates by provider at the agreement level. This prefix gets attached to the
provider’s agreement in the Related Prefixes section tab.

Page 2 of 5
When ambulatory surgical claims are received, Facets will review the ‘Primacy Based On’ field in the
ASC Multiple Procedures application to determine which line is primary and priced at 100% of the
allowable rate. The allowable rate will be entered in the Room Type Profile application. The
additional claims lines will be priced according to the percentages listed in the Indicative section of
this application.

Service Definition Application (AGSE)

The Service Definition application is the basis for pricing and member benefits. It is the only required
prefix for an agreement. The Service Definition on the agreement is provider-specific versus the
Service Definition on the Product, which is the default. The Service Definition table allows different
referral, preauthorization, capitation and risk withholding requirements to be applied to all providers
accessing this agreement.

Auto Room Type Application (AGRT)

Identifies the room type entry that is required to obtain pricing values for All Inclusive Room and
Board and Per Diem and Per Case hospital priced claims. The Auto Room Type prefix gets attached to
the provider’s Agreement application in the Related Prefixes section tab. During claims processing,
the room type is automatically generated based on criteria entered in the application. Once the room
type is found, Facets will then determine the correct pricing values for the room by using the Room
Type Profile Application.

Delegated Services Application (AGDC / ADGU)

This application allows the user to identify Service IDs that will be linked to a provider agreement on
the Related Prefixes section tab of the Agreement, Medical application. These services are delegated
specifically to claims processing or UM, and allow an organization to specify the services that can be
delegated for a provider within a specific medical agreement.

MCOs may contract with agencies or provider groups to delegate the processing of claims,
referral/pre-authorization and case management episodes. Facets allows MCOs to identify the
delegated entities as well as the services and provider agreements that are associated with these
entities. As a result, customers can be alerted to any delegated services, and the associated line-items
can be denied or issued a warning message.

For example, HMO-A has delegated all claims, referrals, pre-authorizations and case management
episodes for its Executive product to the Claims Payor Company. When a claim is submitted, Facets
determines if any of the line-items contain services that have been delegated. Only the non-
delegated services will be paid and the delegated services will be denied.

Page 3 of 5
DRG Rules Application (AGRG)

This application is used to establish pricing rules for DRG codes. If this agreement is linked to DRG
pricing, the DRG Rules table defines the accepted DRG codes, the pricing associated with those codes,
and sets outlier and stoploss parameters for each DRG. The prefix for this application gets attached to
the provider’s Agreement application in the Related Prefixes section tab. A DRG Profile is also
required.

Inlier Application (AGIL)

The Inlier application is used to define a different discount pricing methodology for inpatient and/or
outpatient claims where a total billed amount is less than a pre-defined percent of the threshold. The
threshold will be determined by computing the threshold percent and comparing it to the billed
charges. If the amount computed was greater than the billed charges, then inlier provisions do not
apply. If the amount computed is lower than the billed charges, then inlier provisions do apply.

Facets will calculate inlier functionality triggered by a dollar amount. The two methods of calculation
included are as follows: 1) If billed charges are less than the allowed, the inlier price is a discount off
the charges, 2) if the billed charges are less than the allowed, billed charges will be multiplied by a set
percent and compared to the allowable for a ‘lesser of’ price.

The Inlier application allows the user to establish inlier pricing that is based on dollar amounts rather
than on length-of-stay. COB will not play a role with this functionality. The prefix gets attached to the
provider’s Agreement application in the Related Prefixes section tab.

Modifier Pricing Rules Application (AGPC)

The Modifier Pricing Rules application is a Related Prefix on the Agreement, Medical application (Type
= AGPC) that allows the user to enter pricing rules for each modifier. This information is used in
conjunction with the Modifier Hierarchy application to determine the final line item price (see
Chapter 7 “Pricing: Reference Guide” for information on the Modifier Hierarchy application and
Multiple Modifier Processing Logic). All Facets claims processing applications allow the user to
perform line item pricing based on the multiple modifiers that have been applied to a line item.
Modifiers are user-defined codes that provide additional information about a particular service and
are factors used in calculating the final price of that service. The Modifier Pricing Rules application is
found in the Medical Plan application group. It can also be a product component with the component
type of MDPC.

This table allows the user to specify a percentage to take when specific modifiers appear on a line
item in a position other than the first. The Modifier Pricing Rules prefix is captured at the claim level.

Page 4 of 5
Procedure Application (AGIP)

The Procedure application is used to identify agreement requirements at the procedure level.
Procedure codes (CPT-4 codes/HCPCS codes) are universal codes that identify different services that
can be performed by a provider, and are used to set-up evaluation, admission and clinical editing
criteria, establish plan pricing structures, and capture utilization review, risk withholding and
capitation information. The prefix gets attached to the provider’s Agreement, Medical application in
the Related Prefixes section tab.

Prompt Payment Discount Application (AGPP)

This application identifies prompt payment discount criteria for the agreement based on the From and
To Days and the Discount Percents. This discount is applied to the paid benefit during the claims
payment batch process. The prefix to this application gets attached to the provider’s Agreement
application in the Related Prefixes section tab.

Stoploss Application (AGSL)

This application is used to define the dollar amount when a Managed Care Organization will alter their
standard agreement pricing logic to limit their liability on a large dollar claim case. The Stoploss table
will apply stoploss options for inpatient and outpatient claims. The Stoploss prefix gets attached to
the provider’s Agreement application in the Related Prefixes section tab.

Profile Pricing

The Fee Schedule Profile application stores fee amounts for specific procedures and is used to pay a
provider a different amount for those indicated procedures. A schedule amount must be established
on the product for each procedure code to be used in a provider’s profile. This application may be
used with both Schedule and Reasonable & Customary pricing arrangements. This application may
also be established for a specific provider, all providers in a network or all providers linked to a
specific agreement. Facets will pay the profile amount set-up here, if previously indicated on the
Service Pricing record. This application gets linked to the provider’s agreement in the Indicative
section tab.

Room Type Profile Application

The Room Type Profile application is used when the medical plan calculates benefit and room rates
based on per diem and/or per case information. This application will identify the different room
types, the rate for each room, and how that rate should be calculated (per diem / per case) in relation
to the number of units identified on a claim line.

Page 5 of 5