Contracts

Insurance contracts - allowable amounts

An insurance contract is an agreement with a payer for a dollar amount that the payer will reimburse your company for services, supplies, and procedures. This is different from charge rates. The amount that you enter in the allowable amounts section of the insurance record is the amount the insurance will pay you while the charge rate is the amount your company charges.

Allowable amounts can be calculated by the flat amount per HCPCS, % of Medicare fee schedule, or % of charge amount.

The allowable amount is configured in Payers and is associated with the benefit plan for that payer.

When you work a claim where there is a contract with the payer, the universal charges are applied to the claim and sent to the clearinghouse. Because of the contractual amounts you entered for the benefit plan, the system knows that the amount you will receive from the payer will be the expected amount not the billed amount. The expected amount displays on the Claim page under the "Expected amounts" tab.

For details on how to configure a payer contract, see Configuring Payers.

Facility contracts

A facility contract is an agreement with a facility for a dollar amount that the facility will reimburse your company for services, supplies, and procedures. This is different from charge rates. The contracted facility amount is the amount the facility agreed to pay your company while the charge rate is the amount your company charges.

For information on how to work with facilities including how to view and add a facility contract, see Contracted Charges.