Provider Rates

Purpose:

Provider Rates document the contracted billing frequencies and rate amount(s) per frequency for a specific Provider Detail. A Provider Detail specifies which Organization will provide a specific Program Service under the terms of the Service Approval. Provider rates are governed by the policy of the DHHS program that covers the Service.

Key Points:

Rate data may be added/changed for any row of active Provider History.
Provider rates must be within the begin and end dates of an active row of Provider History
A rate row may not overlap another row for the same frequency.
An instance of Provider Rate must contain a Frequency, Begin Date and an amount in at least one of the three rate field (amount, maximum or minimum).
The begin date may be back dated as long as it is within the begin and end date of the active row of Provider History and does not cross another row for the same frequency.
A change in the Begin date associated with a rate decrease must be equal to or greater than the current date
A change in the Begin date associated with a rate increase may be past, current or future date.
The end date may be shortened as long as the new date is equal to or greater than current date.
The end date may be extended as long as it meets rules regarding Provider History and does not cross another row for the same frequency.

Some providers have Provider Rates that allow them to bill different rates for he same frequency and time period. If the Provider rates have amounts entered in the Minimum and Maximum fields, multiple rates between the two amounts can be entered in the Units and Rates box in the Service Authorizations.