SecurityChoice Payment Methodology Grid

The SecurityChoice Payment Methodology Grid describes how we calculate Medicare Reimbursement rates.

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SecurityChoice Payment Methodology Grid
Acute Care Hospital Inpatient Services	UniCare will calculate the Medicare Base Payment Rate, any Outlier amount, Operating Expense, Capital Expense, Disproportionate Share, Organ Acquisition costs and Transfer Payments.
Acute Care Hospital Outpatient Services	UniCare will utilize the Outpatient National Medicare Provider Rate File (ONMPRF) to group/price APC claims for ANY Medicare-approved provider. When processing an APC claim, components that comprise the total reimbursement amount (i.e. accounting for outliers, drugs and devices paid as passthroughs) will be included.
Ambulance Independent and Provider Based	Blended method between reasonable charge for ambulance supplier and national fee schedule. Reasonable charge for provider is added to the correct percentage of the national fee schedule for that year to arrive at payment. If necessary, ambulance company can submit Medicare RA showing correct amount.
Anesthesia/ Physician Performed	UniCare will calculate according to Medicare's methodology: Medicare anesthesia conversion factor by locality x sum of uniform base units + time units.
Anesthesia Physician Medical Direction of 2 or more Nurse Anesthetists concurrently	UniCare will calculate according to Medicare's methodology: Medicare anesthesia conversion factor by locality x sum of uniform base units + time units.
Ambulatory Surgical Center	Utilize fee schedules via CMS or intermediary website.
Assistant at Surgery (Physicians)	If physician is assistant, payment is 16% MFS. If physician assistant is assistant, payment is 85% times 16% MFS.
Blood	Reimbursed under OPPS for hospital outpatient services.
Braces	100% of the Medicare Durable Medical Equipment Prosthetic, Orthotic, and Supplies Fee Schedule. Covered when furnished incident to physicians' services or on a physician's order.
Cancer Hospitals Inpatient Services	UniCare will contact facility for their pricing information. Facility can submit copy of Medicare RA showing correct pricing.
Cancer Hospitals Outpatient Services	UniCare will utilize the Outpatient National Medicare Provider Rate File (ONMPRF) to group/price APC claims for ANY Medicare-approved provider.
Certified Registered Nurse Anesthetist (CRNA)	UniCare will calculate according to Medicare's methodology: Medicare anesthesia conversion factor by locality x sum of uniform base units + time units. Payment is made on an assignment basis only. The above allowance is divided equally between the anesthesiologist and the anesthetist (50% each).
Clinical Nurse Specialist	85% of Medicare Fee Schedule.
Clinical Psychologist	100% of Medicare Fee Schedule.
Clinical Social Workers	75% of Medicare Fee Schedule.
Clinical Trial Services	Medicare directly reimburses all approved clinical trial services provided to an M+C enrollee according to the appropriate fee for service methodology.
Community Mental Health Centers	UniCare will utilize the Outpatient National Medicare Provider Rate File (ONMPRF) to group/price APC claims for ANY Medicare-approved provider.
CORF	Reimbursement based on the Medicare physician fee schedule. Vaccines reimbursed under the OPPS.
Co-Surgeons	For each co-surgeon, the payment amount is 62.5% of the global surgery under the Medicare fee schedule.
Co-Surgeons Team Surgery	Team surgery reimbursement is "by report."
Critical Access Hospital (CAH)	CAH’s will be reimbursed the current Medicare allowable rate for all Medicare covered services. UniCare will utilize the 100+1% of Medicare Interim rate that applies to CAH. Additionally, UniCare agrees to review CAH’s most recent two (2) Medicare cost settlement summaries and increase CAH’s current interim rate by the average percentage increase from these two (2) Medicare cost settlements, up to 100+5%. Interim rate adjustments are effective for one calendar year and will be validated during the month of December each year. CAH agrees to forward most current Medicare cost settlement summaries as they become available. UniCare will recalculate the interim rate adjustments on a quarterly basis.
Diabetic Shoes	Only covered for certain conditions with annual limit. Reasonable charge subject to payment limits.
Drugs	Reimbursement calculated using CMS fee schedules. Medicare-covered outpatient drugs/biologicals that qualify for pass-through payments will be processed.
Durable Medical Equipment	Reimbursement calculated using CMS fee schedules.
Epoetin (EPO)	EPO is paid $10 per 1,000 units when administered by an ESRD facility or provider. Otherwise, it is paid 95% AWP.
ESRD Facility	UniCare will contact facility for pricing information, including exception payments. If necessary, facility can submit copy of Medicare RA showing correct pricing.
FQHC Independent and Provider Based	UniCare will contact facility for pricing information. If necessary, facility can submit copy of Medicare RA showing correct pricing.
Hemophilia clotting factors billed by provider (eg. Hospital, SNF, HHA)	Add on payment for beneficiaries in an inpatient setting. Outpatient setting paid on a cost basis. All other settings (SNF, HHA) paid under the Single Drug Pricer.
Hemophilia clotting factors billed by supplier (eg. DME supplier, independent pharmacy, Red Cross)	Reimbursed under the Single Drug Pricer.
Home Dialysis Supplies & Equipment	Method I or II per Medicare.
Home Health Agencies Independent and Provider Based	Reimbursement calculated using pricer via CMS Web site.
Home Infusion	Reimbursement per Medicare Durable Medical Equipment Prosthetic, Orthotic, and Supplies Fee Schedule for applicable services.
Hospital Transfer Acute to Acute	Transferring hospitals are reimbursed a per diem rate. The per diem rate is the full DRG amount divided by the geometric mean length of stay for the DRG. Twice the per diem is paid on the first day and the per diem for every following day up to the transfer or the full DRG amount. Transfer cases classified into DRG 385 are paid at the full DRG instead of the per diem methodology.
Hospital Transfer Acute to Postacute	Expanded Transfer Definition: A qualified discharge from one of 10 DRGs to a postacute care provider will be treated as a transfer case and reimbursed the per diem methodology stated above, with the following exception: DRGs 209, 210 and 211 are paid under a methodology where 50% of the DRG plus the per diem is paid on the first day of the stay. For each subsequent day, 50% of the per diem is paid up to the full DRG amount.
Immunosuppressive Drugs, transplant	Paid under OPPS if beneficiary is in the outpatient department of a Medicare participating hospital. In all other settings, 95% average wholesale price.
Indian Health Service Facility (IHS) Inpatient Services	UniCare will utilize the National Medicare Provider Rate File (NMPRF) to group/price DRG claims for ANY Medicare-approved provider.
Indian Health Service Facility (IHS) Outpatient Services	All-inclusive rate. Excluded from OPPS. Fee schedule for outpatient professional services.
Injections	Specific injection services are paid separately if physician does not render other services at the time of the injection. Chemotherapy injections are paid in addition to the visit for same day of service.
Laboratory	Reimbursement calculated using CMS fee schedules.
Mammography Screening	100% of Medicare Fee Schedule.
Maryland Hospitals	HSCRC mandated rate thresholds. Reimbursed 94% of approved charges for IP and OP services.
Medical Nutrition Therapy	85% of the Medicare Fee Schedule.
Medicare Dependent Hospital Inpatient Services	UniCare will utilize the National Medicare Provider Rate File (NMPRF) to group/price DRG claims for ANY Medicare-approved provider.
Medicare Dependent Hospital Outpatient Services	UniCare will utilize the Outpatient National Medicare Provider Rate File (ONMPRF) to group/price APC claims for ANY Medicare-approved provider.
Nurse Practitioner	85% of the Medicare Fee Schedule.
Oral Anti-Cancer Drugs	95% of the average wholesale price as identified in the Drug Topics Red Book.
Oral Anti-Nausea	Furnished by physician/supplier, reimbursed at 95% of the median average wholesale price.
Parenteral and Enteral Nutrition	PEN Fee Schedule.
Physical Therapy, Occupational Therapy, Speech Therapy	100% of Medicare Fee Schedule.
Physician(MD)	Reimbursement calculated using CMS fee schedules. Physician Services are priced according to the Correct Coding Initiative (CCI) edits and payment rules are configured to follow Local Medical Review Policies.
Physician (DO)	Reimbursement calculated using CMS fee schedules. Physician Services are priced according to the Correct Coding Initiative (CCI) edits and payment rules are configured to follow Local Medical Review Policies.
Physician (Podiatrist)	100% of Medicare Fee Schedule.
Physician (Chiropractor)	100% of Medicare Fee Schedule.
Physician (Optometrist)	100% of Medicare Fee Schedule.
Physician (Dentist)	100% of Medicare Fee Schedule.
Physician (Oral and Maxilofacial Surgeon)	100% of Medicare Fee Schedule.
Physician Assistant	85% of Medicare Fee Schedule.
Prosthetic Devices	100% of the Medicare Durable Medical Equipment Prosthetic, Orthotic, and Supplies Fee Schedule.
Psych Hospital Inpatient and Outpatient Services	UniCare will contact facility for their pricing information. If necessary, facility can submit copy of Medicare RA showing correct pricing.
Registered Dietitian	85% of Medicare Fee Schedule.
Rehab Hospital Inpatient Services	Reimbursement calculated using pricer via CMS Web site.
Rehab Hospital Outpatient Services	UniCare will utilize the Outpatient National Medicare Provider Rate File (ONMPRF) to group/price APC claims for ANY Medicare-approved provider.
Religious Non-Medical Health Care Institutions	UniCare will contact facility for their pricing information. If necessary, facility can submit copy of Medicare RA showing correct pricing.
Rural Health Clinic Independent and Provider Based	UniCare will contact facility for their pricing information. If necessary, facility can submit copy of Medicare RA showing correct pricing.
Skilled Nursing Facilities (SNFs) Independent and Provider Based	Reimbursement calculated using pricer via CMS Web site.
Surgical Dressings	The Medicare DMEPOS fee schedule applies to all surgical dressings except those applied incident to a physician's professional services, those furnished by an HHA and those applied while a patient is being treated in an outpatient hospital department or as an acute care inpatient. Hospital outpatient reimbursed under PPS (APCs) HHA's payment is bundled into PPS (HHRGs). If a physician, certified midwife, physician assistant, nurse practitioner, or clinical nurse specialist applies surgical dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered incident to the professional services of the health care practitioner.
Swing Beds	Reimbursement calculated using pricer via CMS Web site.
VA Hospitals	Federal providers are excluded from participation in the Medicare program. However, Federal Hospitals, like other non-participating hospitals may be paid for emergency inpatient and outpatient hospital services. Hospital filed claims: Inpatient: lower of actual charges or rates published for Federal Hospitals in the Federal Register under OFFICE OF MANAGEMENT & BUDGET - Cost of Hospital & Medical Care & Treatment. Outpatient: 85% of the total covered charges.
X-Ray	100% of Medicare Fee Schedule.