An allowable fee, or allowance, is determined for each service and supply you provide to our members. This allowance can vary with the type of benefits the member has and with the type of provider agreement(s) you have signed (e.g., professional or facility).
Provider reimbursement schedules and other pricing documents are available in Availity Essentials: Claims & Payments>Fee Schedule Listing.
Most professional allowances are calculated by multiplying resource-based relative value scale (RBRVS) RVUs by contracted conversion factors assigned to procedure codes. The most commonly-used RVUs are published annually by the Centers for Medicare & Medicaid Services (CMS) in the Federal Register, although we may also use RVUs published by St. Anthony's relative values in the absence of CMS RVUs. Conversion factors are assigned to procedure code ranges by us and are reviewed periodically.
Site of service refers to the method of calculating reimbursement for services based on the setting in which they were provided. Services that can be provided both in office and facility settings will have both facility and non-facility RVUs listed in the Federal Register. In general, reimbursement calculations for office-based services are made using non-facility RVUs, and for facility-based services using facility RVUs. If only one RVU is listed (e.g., facility or non-facility), that RVU will be used to calculate reimbursement regardless of treatment setting.
CMS criteria is used in determining the place of service settings where professional provider's services are reimbursed at the facility rate.
Not all procedure codes have RVUs published in the Federal Register or St. Anthony's. In these cases, allowances are administratively set by us using various methods. These include using published fee schedules, such as those used to calculate Medicare payment for laboratory procedures or durable medical equipment.
Visit asurisdental.com for dental reimbursement information.
Effective January 1, 2023, the reimbursement schedule amounts for covered services provided to Medicare Advantage members by dental provider shall be based upon the lesser of 1. allowable billed charges; or 2. the maximum allowable, determined by your network participation status in the following networks:
- United Concordia Dental
- DenteMax
- Asuris Participating Dental
Asuris reserves the right to enter into additional agreements to rent or otherwise gain access to other provider networks in which dental providers may participate. Asuris shall place any additional networks within the list above or modify it by providing at least 60 days’ advance notice.
For the Asuris Participating Dental fee schedule, please visit Availity Essentials. For questions related to your participating agreement with United Concordia or DenteMax, please contact them directly using the online services provided.
- Visit the United Concordia Dental website or call 1 (800) 307-8514.
Complete the DenteMax online request form.
Effective May 1, 2022, we increased the reimbursement rates for hearing aids. The May 1, 2022 change applies to all commercial lines of business and plans, regardless of benefit limits.
Excluded: Medicare Advantage members and facilities.
If a member chooses to upgrade to a hearing aid product above our reimbursement cap, the member should complete a Non-Covered Services Member Consent Form.
In this case, providers should use HCPCS S1001 Deluxe item, patient aware (list in addition to code for basic item) when billing for the cost in excess of the standard product. The signed Non-Covered Services Member Consent Form must accompany the bill and be on file if a health care service requests the form at a future date.
Providers with standard (non-negotiated) agreements with Asuris and suppliers can check reimbursement rates for hearing aids on Availity Essentials: Claims & Payment>Fee Schedule Listing>Fee Schedules.
Providers with negotiated agreements will need to call our Provider Contact Center to determine reimbursement for hearing aid codes.
Participating providers have agreed to accept our allowable fee as payment in full for covered services and supplies, whether paid by us, our member or another payer. This means you may only charge our members for deductible, coinsurance, copayments and non-covered services. You must write-off (or "hold the member harmless") for other amounts as shown below. These write-offs are also known as adjustments and are indicated on your provider voucher. Please reference your agreement for further clarification.
- Charges above Maximum Allowable Fee: You must hold harmless any amount of your charge that is over the allowance. For example, if you charge $45.00 for a service with a $43.00 allowance, you must not charge the member for the $2.00 difference.
- Charges denied due to medical or reimbursement policies: You must hold harmless any amount deemed a provider write-off based on our medical or reimbursement policies, including services or supplies determined not medically necessary. Changes in policy are normally sent via provider newsletters or letters from the Medical Director or company officer, or amendments to your agreement.
- Charges related to associated claims: Claims for associated services rendered to support an investigational, non-covered or not medically necessary service—including anesthesia, pathology, hospital and laboratory—will be denied. Associated claim denials can occur in conjunction with pre- or post-payment reviews or on appeal.
- Claims for investigational or non-covered services are denied as patient responsibility; however, you must hold harmless any amount for associated claims related to services determined by us to be not medically necessary. We will consider a non-covered member consent form (PDF) obtained by the provider of the primary service valid for all associated claims if the primary provider indicates a consent form has been signed.
We pay providers directly in accordance with the federal No Surprises Act. This federal mandate ends surprise medical bills by holding the patient harmless for care in:
- Emergency services regardless of network status
Non-emergency situations when services are performed by out-of-network (OON) providers at in-network facilities
The act also requires insurance companies to pay OON providers directly.
Professional claims from providers who have acquired a Notice of Surprise Billing and Consent by the member to allow you to bill balances outside of member cost-share must submit their electronic claim(s) by populating the PWK segment with a value of “CK” to indicate that you acquired a signed notice and consent from the member. If this information is not reflected in the EDI portion of the claim, your claim(s) will be processed according to the Federal No Surprise Act using the Qualified Payment Amount and balances must be written-off.
Note: Washington state law does not allow providers to acquire notice and consent from members on fully insured groups or self-funded groups that have opted into the Washington state mandate.
The administrative policies and guidelines that we use to review and pay claims are important and integral to the relationship we share with our participating providers. When establishing our policies, we attempt to adopt widely accepted community policies and standards when they are available and supportable. In keeping with this, we use CMS' NCCI edit data with our claims processing system. In addition, we have identified correct coding edits to supplement NCCI.
Correct coding edits identify component service codes that are inappropriately reported as separate and distinct services from the comprehensive code. In comprehensive and component codes edits, the comprehensive code will be reimbursed to contract benefits and the component code will be considered included in the comprehensive code.
Our Correct Code Editor (CCE) houses the correct coding edits and is updated quarterly (January, April, July and October.) Coding changes occurring in the updates are effective for dates of service on or after the installation date and no claims will be adjusted retrospectively.
All lines of business will use CCE. NCCI logic will apply first, then supplemental CCE edit logic will apply when a claim is being adjudicated. Feedback may be submitted by contacting us.
If you have a specific question or concern regarding a specific claim, please follow the provider billing dispute and medical necessity procedure determination appeal process.
Correct Coding Solutions, LLC, develops and refines NCCI, coordinates the receipt of comments, the prioritization of issues, the review and research of previous actions and the discussion with CMS about the concerns. Correct Coding Solutions accepts written comments via mail or fax at:
National Correct Coding Initiative
Correct Coding Solutions, LLC
P.O. Box 907
Carmel, IN 46082-0907
Fax: (317) 571-1745