Globally Update Pricing in a Contract Library

You can globally update the pricing in payer fee schedules in a contract library. This kind of update calculates the allowed and reimbursement amounts by using RVU and GPCI information.

To globally update the pricing in a contract library:

In File Maintenance, select Libraries > Contracts.
Right-click the applicable library, and then select Contract Global Update.

The Contract Global Update window opens.
Enter a CPT4 code range by typing a CPT4 code in the CPT4 field and another CPT4 code in the Thru CPT4 field, and the effective date of the CPT4 codes in the Effective Date field.
To use RVU and GPCI information to calculate the price, do the following:
1. Select the RVU library.
2. Select a GPCI library, if necessary, and then select a carrier or locality.
3. If you want to use the RVU library to calculate the SIM RVU, select an RVU in the RVU field (this list of RVUs comes from the RVU library), and then the GPCI value in the GPCI field.
4. You can select up to three RVUs and GPCIs to use in the calculation. Each RVU is multiplied by a GPCI and the results are added together. For example: (RVU1 x GPCI1) + (RVU2 x GCPI2) = SIM RVU
  
  Note: If you select zero ( 0) as the RVU or GPCI value, the result of the multiplication is zero. If you select 1, the result is equal to the other factor.
Enter the conversion factor or, if the price is anesthesia-related, enter the Anesthesia conversion Factor. The conversion factor is the Medicare conversion factor that the RVU and GPCI calculation (geographically adjusted RVU) is multiplied by to get a dollar payment amount. For example, in 2006 the conversion factor was 31.177.
Set the percentages for the allowed and reimbursement amounts:
Set the New Allowed Amount to XX of the Calculated Payment (Adjusted RVU*Conversion Factor) – The default is 100%.

Set the New Participating Reimbursement Amount to XX of the new allowed amount – The default is 100%.

Determine the New Non-Participating Allowed Amount to XX of the new allowed amount = The default is 95%. This percentage is used in calculating the Non Participating Reimbursement Amount below. It does not set any value since there is no Non-Participating Allowed Amount in the contract library.

Set New Non-Participating Reimbursement Amount to XX of the determined Non-Participating Allowed Amount – The default is 80%
If you want to retain settings for the existing CPT4 codes in the filter range, then select Keep Existing Values for Old Fee Schedules.
To specify the settings for all CPT4s in the range, set the following: You can see the changes on Contract Library Maintenance > Fee Schedule tab.
- Type - Select either FFS or Capitated.
- Auth Required – Select to make authorization required.
- Refer Required – Select to make referrals required. If you want to use a dollar amount or a percentage to calculate the pricing, select Co-Pay. Select the Dollar or the Percent option to determine whether the pricing update is based on a dollar or percentage amount, and then enter a numeric value.
Note: If Keep Existing Values for Old Fee Schedules is selected, the new settings apply to any CPT4s that do not have these settings selected. If Keep Existing Values for Old Fee Schedules is not selected, these settings apply to all the CPT4s.
Select either Update the Non-Facility Price or Update the Facility Price to update the pricing in the Non-Facility or Facility rows on Contract Library Maintenance > Fee Schedule tab.

Note: To update facility and non-facility prices, run the update twice – once for facility and once for non-facility.
Do one of the following:
- To create a new row of prices for each code, select Expire Old, and create new row in Contract.
- To update pricing in existing rows, select Update the Existing Row in the Contract
Enter the new effective and expiration dates in Effective Date and Expiration Date fields.
Select OK.
The Contract Global Update List window opens. All of the check boxes for the listed SIM records are selected for updating.
If there are CPT4s listed that you do not want updated, then you need to clear their check boxes.
Select one of the following:
- Update – A message confirms that you want to create new prices for the selected CPT4s. Select Yes to update the pricing and generate a report of the changes or select No to cancel the pricing update process.
- Report – A message warns that the update process will cancel if you run the report. Select Yes to run the report or select No to cancel the report.
The Contract Global Update report opens.

You can globally update the pricing in payer fee schedules in a contract library. This kind of update calculates the allowed and reimbursement amounts by using RVU and GPCI information.

To globally update the pricing in a contract library:

In File Maintenance, select Libraries > Contracts.
Right-click the applicable library, and then select Contract Global Update.

The Contract Global Update window opens.
Enter a CPT4 code range by typing a CPT4 code in the CPT4 field and another CPT4 code in the Thru CPT4 field, and the effective date of the CPT4 codes in the Effective Date field.
To use RVU and GPCI information to calculate the price, do the following:
1. Select the RVU library.
2. Select a GPCI library, if necessary, and then select a carrier or locality.
3. If you want to use the RVU library to calculate the SIM RVU, select an RVU in the RVU field (this list of RVUs comes from the RVU library), and then the GPCI value in the GPCI field.
4. You can select up to three RVUs and GPCIs to use in the calculation. Each RVU is multiplied by a GPCI and the results are added together. For example: (RVU1 x GPCI1) + (RVU2 x GCPI2) = SIM RVU
  
  Note: If you select zero ( 0) as the RVU or GPCI value, the result of the multiplication is zero. If you select 1, the result is equal to the other factor.
Enter the conversion factor or, if the price is anesthesia-related, enter the Anesthesia conversion Factor. The conversion factor is the Medicare conversion factor that the RVU and GPCI calculation (geographically adjusted RVU) is multiplied by to get a dollar payment amount. For example, in 2006 the conversion factor was 31.177.
Set the percentages for the allowed and reimbursement amounts:
Set the New Allowed Amount to XX of the Calculated Payment (Adjusted RVU*Conversion Factor) – The default is 100%.

Set the New Participating Reimbursement Amount to XX of the new allowed amount – The default is 100%.

Determine the New Non-Participating Allowed Amount to XX of the new allowed amount = The default is 95%. This percentage is used in calculating the Non Participating Reimbursement Amount below. It does not set any value since there is no Non-Participating Allowed Amount in the contract library.

Set New Non-Participating Reimbursement Amount to XX of the determined Non-Participating Allowed Amount – The default is 80%
If you want to retain settings for the existing CPT4 codes in the filter range, then select Keep Existing Values for Old Fee Schedules.
To specify the settings for all CPT4s in the range, set the following: You can see the changes on Contract Library Maintenance > Fee Schedule tab.
- Type - Select either FFS or Capitated.
- Auth Required – Select to make authorization required.
- Refer Required – Select to make referrals required. If you want to use a dollar amount or a percentage to calculate the pricing, select Co-Pay. Select the Dollar or the Percent option to determine whether the pricing update is based on a dollar or percentage amount, and then enter a numeric value.
Note: If Keep Existing Values for Old Fee Schedules is selected, the new settings apply to any CPT4s that do not have these settings selected. If Keep Existing Values for Old Fee Schedules is not selected, these settings apply to all the CPT4s.
Select either Update the Non-Facility Price or Update the Facility Price to update the pricing in the Non-Facility or Facility rows on Contract Library Maintenance > Fee Schedule tab.

Note: To update facility and non-facility prices, run the update twice – once for facility and once for non-facility.
Do one of the following:
- To create a new row of prices for each code, select Expire Old, and create new row in Contract.
- To update pricing in existing rows, select Update the Existing Row in the Contract
Enter the new effective and expiration dates in Effective Date and Expiration Date fields.
Select OK.
The Contract Global Update List window opens. All of the check boxes for the listed SIM records are selected for updating.
If there are CPT4s listed that you do not want updated, then you need to clear their check boxes.
Select one of the following:
- Update – A message confirms that you want to create new prices for the selected CPT4s. Select Yes to update the pricing and generate a report of the changes or select No to cancel the pricing update process.
- Report – A message warns that the update process will cancel if you run the report. Select Yes to run the report or select No to cancel the report.
The Contract Global Update report opens.

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