Flat Fee—If the cap code is set to F, the cap rate will contain the actual amount. This amount then becomes the allowed amount and is subject to the deductible and coinsurance rates.

relative value units All procedures can have Relative Value Units assigned to them. These units assess the complexity of the procedure. Pricing can be calculated by multiplying a predetermined unit multiplier by the relative value enits to determine the allowed amount or based on a set fee schedule.—use the procedure source code in the schedule to locate the relative value for the procedure. The relative value might be expressed as a dollar amount or a unit value.

Note: For Basic pay type, if the cap code is blank, the default is R.

UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. Value—Use the schedule-defined path to locate a UCR The Usual, Customary, and Reasonable amounts allowed for a procedure. UCR compares the charge for a procedure to the amount other doctors have charged for the procedure. UCR data can be external data obtained from HIAA or MDR by geographic area, or can be compiled internally. The allowed determination can be based on a percentile; for example, the 85th percentile would cover the charges of 85% of the doctors who submitted bills. amount. First check for a schedule path at the benefit code level. If no path exists at this level, the schedule default path will be used.

The lesser of considered amount and relative value. Use the procedure source code to locate the the relative value for the procedure in the schedule.

Minimum Relative Value—Similar to R above in determining the relative value. Compare the relative value to the minimum benefit (defined in the cap rate). The relative value amount will be allowed unless it is less than the minimum benefit, in which case, the minimum benefit will be allowed.

Note: If the billed amount is less than the minimum benefit, the billed amount will be allowed.

Minimum UCR—determine the UCR amount by following the path defined in the schedule. Compare the UCR to the minimum benefit (defined in the cap rate.) The UCR amount will be allowed unless it is less than the minimum benefit, in which case, the minimum benefit will be allowed.

Note: If the billed amount is less than the minimum benefit, the billed amount will be allowed.

Minimum UCR—determine the UCR amount by following the path defined in the schedule. Compare the UCR to the minimum benefit (defined in the cap rate.) The UCR amount will be allowed unless it is less than the minimum benefit, in which case, the minimum benefit will be allowed.

Note: If the billed amount is less than the minimum benefit, the billed amount will be allowed.

This cap code is used specifically if both Basic and Major Medical use UCR codes and the Major Medical path is different from the Basic path.

Note: Under Major Medical, if the cap code is blank, the default U is used.

The lesser of the considered amount and UCR amount. Determine the UCR amount by following the path defined in the schedule, then compare the UCR to the considered amount and use the lower value.