What Is Reimbursement Classification?
Reimbursement classification breaks down payment arrangements in contracts into structured, comparable formats. It ensures consistency across payers and networks.Fee Schedules
Each schedule includes:- Title (Specialist Rates, Primary Care Schedule)
- Primary Methodology (current year Medicare, fixed year Medicare, custom, payer-controlled, unknown)
- Scope Summary (services, providers, networks covered)
- Effective Dates
Payment Methodologies
- Current Year Medicare: Rates tied to the current year’s schedule
- Fixed Year Medicare: Based on a specified past Medicare schedule
- Custom: Explicit dollar amounts or custom tables
- Payer Controlled: Determined by the payer’s internal fee schedule
- Unknown: Not clearly defined
Reimbursement Sections
- Individual payment rules
- Network applicability (commercial, Medicare Advantage, Medicaid, Tricare)
- Billing codes associated with each rule
Materialization Process
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Rate Calculation
- Medicare-based: Uses PriceMedic’s schedule builder
- Custom: Extracted from attachments or tables
- Payer-controlled: Linked from payer’s internal schedules
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Output Format
Standardized tables with:- Billing code
- Modifier
- Setting (facility or non-facility)
- Allowable amount
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Source Documentation
- Page references
- Contract excerpts
- Cross-references to exhibits or appendices
Materialized schedules create a consistent dataset for analysis, comparison, and negotiation.