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* Provider reference file (#292)

* allowing for a normalized way to include provider groups into the main file.

* initial documentation for the provider reference

* fixing markdown documentation errors

* minor version bump for provider references

* Table of contents (#291)

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* removing old documentation.

* fixing schema rules. Updating table of contents documentation

* Documentation fix (#327)

* Develop (#320)

* Provider reference file (#292)

* allowing for a normalized way to include provider groups into the main file.

* initial documentation for the provider reference

* fixing markdown documentation errors

* minor version bump for provider references

* Table of contents (#291)

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* removing old documentation.

* fixing schema rules. Updating table of contents documentation

* fixing readme documentation to match in-network schema

* version bump

* linking provider reference examples

* fixing markdown error

* Modifier codes (#334)

* Develop (#320)

* Provider reference file (#292)

* allowing for a normalized way to include provider groups into the main file.

* initial documentation for the provider reference

* fixing markdown documentation errors

* minor version bump for provider references

* Table of contents (#291)

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* removing old documentation.

* fixing schema rules. Updating table of contents documentation

* introducing modifiers into the negotiated rates object

* adding code modifiers to documentation with simple examples.

* array of modifier codes allowing for multiple negotiated rates to be grouped together.

* version bump based on modifier inclusion

* adding billing code modifiers to allowed amounts schema/example

* Provider reference internal (#341)

* Develop (#320)

* Provider reference file (#292)

* allowing for a normalized way to include provider groups into the main file.

* initial documentation for the provider reference

* fixing markdown documentation errors

* minor version bump for provider references

* Table of contents (#291)

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* removing old documentation.

* fixing schema rules. Updating table of contents documentation

* updating the internal reference objects to support provider groups as an array.

* version bump

* Create multiplan-empty-example (#337)

* Create multiplan-empty-example

Would this be an example of the allowed amount multiple plan empty example?

* Rename multiplan-empty-example to multiplan-empty-example.json

Co-authored-by: scott haselton

* Create multiplan-example_allowed-amounts (#345)

* Create multiplan-example_allowed-amounts

Is this an example of the multi-plan allowed amounts file?

* Rename multiplan-example_allowed-amounts to allowed-amounts-multiple-plan-sample.json

Co-authored-by: scott haselton

* External references (#342)

* Develop (#320)

* Provider reference file (#292)

* allowing for a normalized way to include provider groups into the main file.

* initial documentation for the provider reference

* fixing markdown documentation errors

* minor version bump for provider references

* Table of contents (#291)

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* removing old documentation.

* fixing schema rules. Updating table of contents documentation

* adding the ability to reference external provider group files within the provider_reference object

* adding 'location' documentation for the provider_reference object

* clairifying documentation with location examples

* fixing MD formatting

* adding the ability to reference external provider group files within the provider_reference object

* adding 'location' documentation for the provider_reference object

* clairifying documentation with location examples

* fixing MD formatting

* adding xml placeholder

* adding temporary xml schema for table of contents

* adding the ability to allow for multiple files to be combined together to make a complete in-network file

* updating example to be more realistic

* version bump

* TOC sample, in_network_files should be an array (#343)

The second instance of in_network_files is not an array. Does not comply with schema. Changing it to an array.

* Updating in_network_files in JSON sample of README (#344)

The JSON sample in the README is not showing in_network_files as an array. Made correction.

* updating example documentation

* ugh, spelling...

* documentation fix

* removing duplicate documentation

* Updated README: in_network_file was not an array (#346)

Found another instance where in_network_file was not an array in the JSON snippet of README.md

* renaming file to match existing naming

* Billing code hotfix (#351)

* Develop (#320)

* Provider reference file (#292)

* allowing for a normalized way to include provider groups into the main file.

* initial documentation for the provider reference

* fixing markdown documentation errors

* minor version bump for provider references

* Table of contents (#291)

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* initial documentation for a table of contents file

* minor markdown formatting fix

* adding an example of table of contents

* adding the actual example for a table of contents

* adding required elements to the schema

* adding test coverage for table-of-contents. Oddly, the JSON schema matcher didn't like the prescription drug file having a  to a URL even though it wasn't included in the test suite

* updating naming convention documentation

* updating schema and readme documentation (and tests) to match the new naming requirements

* renaming example files

* removing duplicate documentation

* removing old documentation.

* fixing schema rules. Updating table of contents documentation

* Adding 'RC' to billing code list. Discussion here: #348

* version bump for latest billing code addition

* Modifier fix (#373)


* fixing billing code modifier placement bug. Thanks @tdflow! Discussion: #361

* version bump

* removing end of line

* fixing some merge issues and updated the actual schema

* additional modifier naming bugs. Discussion: #12 (#374)

* Percentage added to negotiated_type (#393)

* adding 'percentage' as an available negotiation type to allow for percentage of billing arrangements

* version bump

* updating documentation

* Introducing custom billing coding types and codes (#394)

* Adding custom code types and custom codes around representing all values for items and services

* making documentation cleaner

* README bug fix

* version bump

* Additional Information text field (#395)

* allowing for the ability to providing contextual informatin related to the negotiated agreement

* updating documentation for how the open text field can be used

* cutting version 1.0 for release

* documentation bug

* updating additional_information documentation

* fixing billing_code_modifier bug. Thanks @tdflow

* Update README.md (#398)

Thanks!

* Update allowed-amounts.json (#399)

remove the billing_class_modifier reference as billing_code_modifier is the field reference that should be used.

Thank you so much @tdfow!

* Perdiem (#400)

* adding support for flagging per diem negotiated arrangements

* updating documentation to be friendlier

Co-authored-by: tdfow <[email protected]>
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shaselton-usds and tdfow authored Mar 2, 2022
1 parent 2df1618 commit fba9de7
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2 changes: 1 addition & 1 deletion VERSION.md
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@@ -1 +1 @@
0.10.1
1.0.0
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Expand Up @@ -20,9 +20,9 @@
},
"service_code": ["01", "02", "03"],
"billing_class": "professional",
"billing_code_modifier": ["25"],
"payments": [{
"allowed_amount": 25.00,
"billing_code_modifier": ["25"],
"providers": [{
"billed_charge": 50.00,
"npi": [1234567891,1234567892,1234567893]
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2 changes: 1 addition & 1 deletion schemas/allowed-amounts/README.md
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Expand Up @@ -37,7 +37,6 @@ The allowed amounts object documents the entity or business and service code in
| **tin** | Tax Identification Number | Object | The [tax identifier object](#tas-identifier-object) contains tax information on the place of business | Yes |
| **service_code** | Place of Service Code | An array of two-digit strings | The [CMS-maintained two-digit code](https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set) that is placed on a professional claim to indicate the setting in which a service was provided. When attribute of `billing_class` has the value of "professional", `service_code` is required. | No |
| **billing_class** | Billing Class | String | Allowed values: "professional", "institutional" | Yes |
| **billing_code_modifier** | Billing Code Modifier | Array | An array of strings. There are certain billing code types that allow for modifiers (e.g. The CPT coding type allows for modifiers). If a negotiated rate for a billing code type is dependent on a modifier for the reported item or service, then an additional negotiated price object should be included to represent the difference. | No |
| **payments** | Payments | Array | An array of [out-of-network payments objects](#out-of-network-payment-object) | Yes |

#### Tax Identifier Object
Expand All @@ -57,6 +56,7 @@ The payment object documents the allowed amounts the plan has paid for the servi
| Field | Name | Type | Definition | Required |
| ----- | ---- | ---- | ---------- | -------- |
| **allowed_amount** | Allowed Amount | Number | The allowed amount must be reported as the actual dollar amount the plan or issuer paid to the out-of-network provider for a particular covered item or service, plus the participant’s, beneficiary’s, or enrollee’s share of the cost. See additional notes. | Yes |
| **billing_code_modifier** | Billing Code Modifier | Array | An array of strings. There are certain billing code types that allow for modifiers (e.g. The CPT coding type allows for modifiers). If a negotiated rate for a billing code type is dependent on a modifier for the reported item or service, then an additional negotiated price object should be included to represent the difference. | No |
| **providers** | Providers | Array | An array of [provider objects](#provider-object) | Yes |

##### Additional Notes
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16 changes: 8 additions & 8 deletions schemas/allowed-amounts/allowed-amounts.json
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Expand Up @@ -66,14 +66,6 @@
"institutional"
]
},
"billing_class_modifier": {
"type": "array",
"items": {
"type": "string"
},
"uniqueItems": true,
"default": []
},
"payments": {
"type": "array",
"items": { "$ref": "#/definitions/payments" },
Expand All @@ -97,6 +89,14 @@
"type": "object",
"properties": {
"allowed_amount": { "type": "number" },
"billing_code_modifier": {
"type": "array",
"items": {
"type": "string"
},
"uniqueItems": true,
"default": []
},
"providers": {
"type": "array",
"items": { "$ref": "#/definitions/providers" },
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7 changes: 7 additions & 0 deletions schemas/allowed-amounts/allowed-amounts.xml
Original file line number Diff line number Diff line change
Expand Up @@ -87,6 +87,13 @@
<allowed_amount>
<type>number</type>
</allowed_amount>
<billing_code_modifier>
<type>array</type>
<items>
<type>string</type>
</items>
<uniqueItems>true</uniqueItems>
</billing_code_modifier>
<providers>
<type>array</type>
<items>
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84 changes: 77 additions & 7 deletions schemas/in-network-rates/README.md
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Expand Up @@ -22,11 +22,11 @@ This type defines an in-network object.

| Field | Name | Type | Definition | Required |
| ----- | ---- | ---- | ---------- | -------- |
| **negotiation_arrangement** | Negotiation Arrangement | String | An indication as to whether a reimbursement arrangement other than a standard fee-for-service model applies. Allowed values: "ffs", "bundle" or "capitation" | Yes |
| **negotiation_arrangement** | Negotiation Arrangement | String | An indication as to whether a reimbursement arrangement other than a standard fee-for-service model applies. Allowed values: "ffs", "bundle", or "capitation" | Yes |
| **name** | Name | String | This is name of the item/service that is offered | Yes |
| **billing_code_type** | Billing Code Type | String | Common billing code types. Please see a list of the [currently allowed codes](#additional-notes-concerning-billing_code_type) at the bottom of this document. | Yes |
| **billing_code_type_version** | Billing Code Type Version | String | There might be versions associated with the `billing_code_type`. For example, Medicare's current (as of 5/24/21) MS-DRG version is 37.2 | Yes |
| **billing_code** | Billing Code | String | The code used by a plan or issuer or its in-network providers to identify health care items or services for purposes of billing, adjudicating, and paying claims for a covered item or service. | Yes |
| **billing_code** | Billing Code | String | The code used by a plan or issuer or its in-network providers to identify health care items or services for purposes of billing, adjudicating, and paying claims for a covered item or service. If a custom code is used for `billing_code_type`, please refer to [custom billing code values](#additional-notes-concerning-billing_code) | Yes |
| **description** | Description | String | Brief description of the item/service | No |
| **negotiated_rates** | Negotiated Rates | Array | This is an array of [negotiated rate details object types](#negotiated-rate-details-object) | Yes |
| **bundled_codes** | Bundled Codes | Array | This is an array of [bundle code objects](#bundle-code-object). This array contains all the different codes in a bundle if `bundle` is selected for `negotiation_arrangement` | No |
Expand All @@ -37,15 +37,15 @@ This type defines an in-network object.
| ----- | ---- | ---- | ---------- | -------- |
| **billing_code_type** | Billing Code Type | String | Common billing code types. Please see a list of the [currently allowed codes](#additional-notes-concerning-billing_code_type) at the bottom of this document. | Yes |
| **billing_code_type_version** | Billing Code Type Version | String | There might be versions associated with the `billing_code_type`. For example, Medicare's current (as of 5/24/21) MS-DRG version is 37.2 | Yes |
| **billing_code** | Billing Code | String | The code used by a plan or issuer or its in-network providers to identify health care items or services for purposes of billing, adjudicating, and paying claims for a covered item or service. | Yes |
| **billing_code** | Billing Code | String | The code used by a plan or issuer or its in-network providers to identify health care items or services for purposes of billing, adjudicating, and paying claims for a covered item or service. If a custom code is used for `billing_code_type`, please refer to [custom billing code values](#additional-notes-concerning-billing_code)| Yes |
| **description** | Description | String | Brief description of the item/service | Yes |

#### Covered Services Object
| Field | Name | Type | Definition | Required |
| ----- | ---- | ---- | ---------- | -------- |
| **billing_code_type** | Billing Code Type | String | Common billing code types. Please see a list of the [currently allowed codes](#additional-notes-concerning-billing_code_type) at the bottom of this document. | Yes |
| **billing_code_type_version** | Billing Code Type Version | String | There might be versions associated with the `billing_code_type`. For example, Medicare's current (as of 5/24/21) MS-DRG version is 37.2 | Yes |
| **billing_code** | Billing Code | String | The code used by a plan or issuer or its in-network providers to identify health care items or services for purposes of billing, adjudicating, and paying claims for a covered item or service. | Yes |
| **billing_code** | Billing Code | String | The code used by a plan or issuer or its in-network providers to identify health care items or services for purposes of billing, adjudicating, and paying claims for a covered item or service. If a custom code is used for `billing_code_type`, please refer to [custom billing code values](#additional-notes-concerning-billing_code)| Yes |
| **description** | Description | String | Brief description of the item/service | Yes |

#### Negotiated Rate Details Object
Expand Down Expand Up @@ -96,18 +96,21 @@ The negotiated price object contains negotiated pricing information that the typ

| Field | Name | Type | Definition | Required |
| ----- | ---- | ---- | ---------- | -------- |
| **negotiated_type** | Negotiated Type | String | There are a few ways in which negotiated rates can happen. Allowed values: "negotiated", "derived", and "fee schedule". See additional notes. | Yes |
| **negotiated_rate** | Negotiated Rate | Number | The dollar amount based on the `negotiation_type` | Yes |
| **negotiated_type** | Negotiated Type | String | There are a few ways in which negotiated rates can happen. Allowed values: "negotiated", "derived", "fee schedule", "percentage", and "per diem". See [additional notes](#additional-notes-1). | Yes |
| **negotiated_rate** | Negotiated Rate | Number | The dollar or percentage amount based on the `negotiation_type` | Yes |
| **expiration_date** | Expiration Date | String | The date in which the agreement for the `negotiated_price` based on the `negotiated_type` ends. Date must be in an ISO 8601 format (e.g. YYYY-MM-DD). See additional notes. | Yes |
| **service_code** | Place of Service Code | An array of two-digit strings | The [CMS-maintained two-digit code](https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set) that is placed on a professional claim to indicate the setting in which a service was provided. When attribute of `billing_class` has the value of "professional", `service_code` is required. | No |
| **billing_class** | Billing Class | String | Allowed values: "professional", "institutional" | Yes |
| **billing_code_modifier** | Billing Code Modifier | Array | An array of strings. There are certain billing code types that allow for modifiers (e.g. The CPT coding type allows for modifiers). If a negotiated rate for a billing code type is dependent on a modifier for the reported item or service, then an additional negotiated price object should be included to represent the difference. | No |
| **additional_information** | Additional Information | String | The additional information text field can be used to provide context for negotiated arrangements that do not fit the existing schema format. Please open a Github discussion to ask a question about your situation if you plan to use this attribute. | No |

##### Additional Notes
For `negotiated_type` there are three allowable values: "negotiated", "derived", and "fee schedule". The value are defined as:
For `negotiated_type` there are five allowable values: "negotiated", "derived", "fee schedule", "percentage", and "per diem". The value are defined as:
* `negotiated`: If applicable, the negotiated rate, reflected as a dollar amount, for each covered item or service under the plan or coverage that the plan or issuer has contractually agreed to pay an in-network provider, except for prescription drugs that are subject to a fee-for-service reimbursement arrangement, which must be reported in the prescription drug machine-readable file. If the negotiated rate is subject to change based upon participant, beneficiary, or enrollee-specific characteristics, these dollar amounts should be reflected as the base negotiated rate applicable to the item or service prior to adjustments for participant, beneficiary, or enrollee-specific characteristics.
* `derived`: If applicable, the price that a plan or issuer assigns to an item or service for the purpose of internal accounting, reconciliation with providers or submitting data in accordance with the requirements of 45 CFR 153.710(c).
* `fee schedule`: If applicable, the rate for a covered item or service from a particular in-network provider, or providers that a group health plan or health insurance issuer uses to determine a participant’s, beneficiary’s, or enrollee’s cost-sharing liability for the item or service, when that rate is different from the negotiated rate.
* `percentage`: If applicable, the negotiated percentage value for a covered item or service from a particular in-network provider for a percentage of billed charges arrangement.
* `per diem`: If applicable, the per diem daily rate, reflected as a dollar amount, for each covered item or service under the plan or coverage that the plan or issuer has contractually agreed to pay an in-network provider.

For `expiration_date`, there may be a situation when a contract arrangement is "[evergreen](https://www.investopedia.com/terms/e/evergreen.asp)". For evergreen contracts that automatically renew on a date provided in the contract, the expiration date you include should be the day immediately before the day of the automatic renewal.

Expand All @@ -117,6 +120,8 @@ In situation where there is not expiration date ([see discussion here](https://g
##### Additional Notes Concerning `billing_code_type`
Negotiated rates for items and services can come from a variety of billing code standards. The list of possible allowed values is in the following table with the name of the standard and the values representing that standard that would be expected if being reported on. For standards that are used for negotiated rate that are not in the following table, please open a [discussion](https://github.com/CMSgov/price-transparency-guide/discussions) to potentially add a new standard to the table.

There are custom `billing_code_type`s defined for the Transparency in Coverage rule. These coding types are prefixed with `CTSM-`. These coding types are meant to help with generic reporting. The complete list can be found the in following table.

| Standard Name | Reporting Value | Additional Information |
| ------------- | --------------- | ---------------------- |
| Current Procedural Terminology | CPT | [American Medical Association](https://www.ama-assn.org/practice-management/cpt/cpt-overview-and-code-approval) |
Expand All @@ -135,3 +140,68 @@ Negotiated rates for items and services can come from a variety of billing code
| Enhanced Ambulatory Patient Grouping | EAPG | [EAPG](https://www.3m.com/3M/en_US/health-information-systems-us/drive-value-based-care/patient-classification-methodologies/enhanced-apgs/) |
| Health Insurance Prospective Payment System | HIPPS | [HIPPS](https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen/HIPPSCodes) |
| Current Dental Terminology | CDT | [CDT](https://www.ada.org/en/publications/cdt) |
| Custom Code Type: All | CSTM-ALL | This is a custom coding type defined for the Transparency in Coverage rule. This value represents all possible coding types under the contractual arrangement |


##### Additional Notes Concerning `billing_code`
The following are custom defined billing codes that can be applied to any `billing_code_type`s:

| Reporting Value | Additional Information |
| --------------- | ---------------------- |
| CSTM-00 | Represents all possible `billing_code` values for the defined `billing_code_type`. Typically this can be used when a negotiated arrangement applies to all codes under a `billing_code_type` |

The following would applied the `negotiated_price` object(s) to all CPT codes:
```json
{
"negotiation_arrangement": "ffs",
"name": "CPT codes",
"billing_code_type": "CPT",
"billing_code_type_version": "2020",
"billing_code": "CSTM-00",
"description": "All CPT codes",
"negotiated_rates": [{
"provider_groups": [{
"npi": [6666666666],
"tin":{
"type": "npi",
"value": "6666666666"
}
}],
"negotiated_prices": [{
"negotiated_type": "negotiated",
"negotiated_rate": 12.45,
"expiration_date": "2022-01-01",
"service_code": ["18", "19", "11"],
"billing_class": "institutional"
}]
}
```

The following would applied the `negotiated_price` object(s) to each `billing_code_type` defined at [here](#additional-notes-concerning-billing_code_type). NOTE: the `billing_code_type_version` would apply to the current plan's year.

```json
{
"negotiation_arrangement": "ffs",
"name": "All coding types",
"billing_code_type": "CSTM-ALL",
"billing_code_type_version": "2022",
"billing_code": "CSTM-00",
"description": "All codes possible",
"negotiated_rates": [{
"provider_groups": [{
"npi": [6666666666],
"tin":{
"type": "npi",
"value": "6666666666"
}
}],
"negotiated_prices": [{
"negotiated_type": "negotiated",
"negotiated_rate": 12.45,
"expiration_date": "2022-01-01",
"service_code": ["18", "19", "11"],
"billing_class": "institutional"
}]
}
```

13 changes: 10 additions & 3 deletions schemas/in-network-rates/in-network-rates.json
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Expand Up @@ -31,7 +31,8 @@
"LOCAL",
"EAPG",
"CDT",
"RC"
"RC",
"CSTM-ALL"
]
},
"billing_code_type_version": {
Expand Down Expand Up @@ -237,10 +238,12 @@
"enum": [
"negotiated",
"derived",
"fee schedule"
"fee schedule",
"percentage",
"per diem"
]
},
"billing_class_modifier": {
"billing_code_modifier": {
"type": "array",
"items": {
"type": "string"
Expand All @@ -254,6 +257,10 @@
"expiration_date": {
"type": "string",
"description": "This is a date format of YYYY-MM-DD"
},
"additional_information": {
"type": "string",
"description": "In situations in which alternative reimbursement arrangements can neither be expressed as a dollar amount nor as a percentage, this open text field can be used to provide information such as, a description of the formula, variables, methodology or other information necessary to understand the arrangement. The open text field may be utilized for reporting only if a plan or issuer cannot disclose its in-network rates as a dollar amount or a percentage."
}
},
"required": [
Expand Down
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