Edit a Contract Profile

The date the contract is available for processing. If a contract profile was changed, you might see multiple activation dates

Status of the contract profile

Dollar amount of the administrative fee imposed when a late payment penalty is applied to the account.

Number of days allowed to appeal a claim for this contract after a denial is received

The date when the Client Audit (customer audit) stage is set to “Complete” status, after the contract is approved by the customer

Indicates the required Agency in the Contract Profile Settings, and includes the following options:

• Medicare
• Medicaid
• Wellmark BCBS
• Pennsylvania Medicaid
• Mississippi Medicaid

The first date when a claim is eligible for write-downs, if the facility accepts write-down files from FinThrive.

Note: The cut over date is set for each contract profile and is based on the facility’s date-type preference (either admit, discharge or submit date). It is entered initially by FinThrive as Admit Date (the default) until otherwise instructed.

Indicates whether the profile is automatically renewed

The period within which the services must be billed to be eligible for reimbursement

The type of claim from which the contracts are repriced, either a UB04 or CMS-1500

Name of the facility or group of facilities in which the contract profile was created

The name of the contract in the system (taken from the request form)

Effective date of the current contract rates

Number of days to be added to the Late Days to determine the late payment penalty

Indicates if a contract profile is ICD-9 or ICD-10 compliant:

• Mixed - Contracts with ICD-9 and ICD-10 codes on the same contract
• ICD-9 - Contracts with ICD-9 codes only
• ICD-10 - Contracts with ICD-10 codes only
• None - Contracts with no ICD codes

Option to ignore modifiers when the Correct Coding Initiative (CCI) edits are applied to accounts repriced by the contract profile. This option is only available when the Perform CCI Edits check box is selected. Both the Perform CCI Edits check box and the Ignore Modifiers on CCI Edits check box must be selected to utilize this option.

The current implementation stage of the profile

The current implementation status; progression within the current implementation stage

The late payment terms (usually in days), if available

The type of late payment penalty applied to this profile. Options include the following:

• None - No late payment penalty is applied
• Interest Percentage - Penalty amount is a specified interest rate applied to each day beyond the late and float days; the annual interest rate is specified in the Late Payment Percentage field
• Percentage of Billed Charges - Penalty amount is a specified percentage of billed charges; the percentage is specified in the Late Payment Percentage field
• Billed Charges - Penalty amount is the amount of the billed charges with no discounts applied.

The percentage used to calculate late payment penalties.

• For Percentage of Billed Charges penalty types, the value in this field specifies the percentage of billed charges to use as the late payment penalty.
• For Interest Percentage penalty types, the value in this field specifies the annual interest rate to apply to the days beyond the late float days. When calculating the penalty, the system calculates the daily compound rate based on the annual rate entered in this field. The daily compound rate is multiplied times the number of days beyond the late days and float days combined and then multiplied times the total expected payment.
  
  Example interest percentage calculation:
  Days to Payment = 65, Late Days = 45, Float Days = 5 or 65 > 50, then 65-50 = 15. Interest % = 10%: Take Expected Payment 10,000 * (15 * Daily Compound Rate {@ 365} %) = 41.17

The maximum number of appeals allowed for a claim.

Selecting this check box lets you group claims multiple primary payor grouping logic

Facility’s ten-digit National Provider Identification (NPI) number required on all claims

Patient type assigned to the account: Inpatient/Outpatient

Option to apply Correct Coding Initiative (CCI) edits to accounts repriced by the contract profile

Option to enable special OHAS (Outpatient Hospital Allowance Schedule) incidental processing.

Note: Contract Manager supports multiple versions of OHAS incidental tables. Select the appropriate version for your contract profile.

Identifies if the Admission Date is used to calculate the LOS for Inpatient claims:

• Blank - The LOS is determined by the Service From - Service To dates.
• Inpatient - The LOS is determined by Value Code 80, if present.

If Value Code 80 is present on the claim, the LOS is determined using the number of covered days.

If Value Code 80 is not present, the LOS is determined using the actual Admit Date and Service To date.

Indicates if FinThrive Contract Inventory personnel created the contract profile shell based on an existing profile.

Identifies the state (AK, AL, AR, and so forth) associated with the profile type. Use this field to distinguish between contracts for Government Programs or Traditional Managed Care plans for different states.

Note: This field is active for all profile types.

Identifies contract profiles by type (either for Government Programs or Traditional Managed Care), and helps track departmental workloads by identifying the type of profile.

Indicates to suppress the Hospital Acquired Condition (HAC) version for this contract profile.

Note: The default value is unselected.

Minimum number of days lead time allowed to terminate the contract

The termination date of the contract, if any is present and the customer has requested it to be included

Indicates whether Covered Days (Field Locator 7) is used for per diem service type reimbursement calculations instead of length of stay. When selected, the system verifies that Length of Stay minus Non-covered Days equals the Covered Days. If not, the calculation is based on Length of Stay.

Note: This option only displays if it has been requested to display for your facility.

Indicates the required Agency in the Contract Profile Settings, and includes the following options:

• 1 – Medicare
• 2 – Medicaid
• 3 – Wellmark BCBS
• 4 – Pennsylvania Medicaid
• 7 – Mississippi Medicaid

Added a Birth Weight option to the Edit Contract Profile page for contracts using the APR-DRG grouper. The following birth weight options are available:

• 0 – None
• 1 – Entered weight only (uses value code 54)
• 2 – Coded weight only
• 3 – Entered or Coded weight
• 4 – Entered or Coded weight with crosscheck
• 5 – Coded weight with default
• 6 – Entered or Coded weight with default
• 7 – Entered or Coded weight with crosscheck and default

Indicates to exclude Complication of Care codes and includes the following options:

• 1 – Compute excluding all complication of care codes
• 0 – Compute excluding only non POA codes

Indicates to suppress the Hospital Acquired Condition (HAC) version for this contract profile.

Note: This option is defaulted to unselected.

The details of the calculation used by the selected COB calculation method. This field is only populated after you select a calculation method in the Calculation Method drop-down list. If COB is enabled for secondary and tertiary claims for your facility, the calculation for both secondary and tertiary payors displays. For more information about COB, refer to Coordination of Benefits.

The COB calculation used when this profile is the secondary product. The details of the calculation method are listed in the drop-down list. When you select a calculation method, the actual calculation for that method appears in the Calculation field. If COB is enabled for secondary and tertiary claims for your facility, you can define a calculation method for both secondary and tertiary payors. For more information, refer to Coordination of Benefits.

Indicates a favorable or unfavorable COB value for this profile. This classification can be used to filter accounts in the Payor Worklist.

• Favorable indicates a likely opportunity to collect for this profile
• Unfavorable indicates a less likely opportunity to collect for this profile

If COB reports are enabled for your facility, this field also determines which report displays the secondary reimbursement detail for claims repriced with this contract profile:

• Secondary Payor Reprice - Favorable Report
• Secondary Payor Reprice - Unfavorable Report

If COB is enabled for secondary and tertiary payors, the language category for both secondary and tertiary payors displays.

Indicates whether the profile performs COB reprice calculations. If COB is enabled for your facility, you can define the reprice option for both secondary and tertiary payors. For more information, refer to Coordination of Benefits.

The rules governing when this DRG grouper version is applied to claims repriced against this contract profile

• Never – Never override the DRG grouper to this version
• When DRG Blank – Only override the DRG grouper to this version when the DRG is missing
• Always – Always override the DRG grouper to this version for all claims repricing against this contract profile.

When the DRG Group Type is APR-DRG and the DRG Grouper Version is APR*, the following rules govern when this DRG grouper version is applied to claims repriced against this contract profile:

• Always – The DRG Grouper automatically selects the appropriate Grouper Version and HAC Version based on the claim date of service as well as the Effective Date and Effective Date Match settings of the DRG Grouper Information. The Grouper is set at the Contract level.
• Never - The DRG Grouper does not regroup the claim. The Grouper is set at the Contract level.
• When DRG or SOI is invalid - The DRG Grouper automatically selects the appropriate Grouper Version and HAC Version based on the claim date of service as well as the Effective Date and Effective Date Match settings of the DRG Grouper Information. However, the claim only groups if either the DRG or the SOI does not exist on the claim or has an invalid value. If the claim has valid values for both the DRG and the SOI, the DRG Grouper does not regroup the claim. The Grouper is set at the Contract level.
• Per Data File – The claim groups based on the Grouper Version and HAC Version set in the Data File for the claim date of service. The Grouper is not set at the Contract Level.

The DRG grouper version used for this contract profile according to the other rules defined in this section.

The DRG grouper version state used for this contract profile. A selection from this drop down list is required when the DRG Grouper Version is APR* and the grouper version’s effective date and/or the HAC version’s effective date is different from the CMS’s effective date.

The effective date in the DRG Grouper Information section displays the date when the defined DRG grouper version goes into effect for the contract profile.

The date used to determine the which DRG grouper version is effective for this contract profile

• ADMIT DATE – Matches the admission date to the DRG grouper effective date
• DISCHARGE DATE – Matches the discharge date to the DRG grouper effective date

Indicates which Hospital Acquired Condition (HAC) version is used for this contract profile.

• This option is only available for contracts using APR-DRG Grouper version APR26 or later.
• This field is automatically populated based on the DRG Grouper Version selected.

Note: For versions prior to APR26, the HAC Version value will be blank.

The patient type in the DRG Grouper Information section displays the patient type this DRG grouper version is applied to, either IP (inpatient only) or IP/OP (both inpatient and outpatient)

The termination date in the DRG Grouper Information section displays the date when the defined DRG grouper version is no longer effective

Indicates if the Present on Admission (POA) indicator is used for this contract profile.

• Yes – Allows the grouper to read the POA indicator on all Inpatient claims. See Note below.
• No – Allows the grouper to ignore the POA indicator on the claim.
• Both – Allows the grouper to read the POA indicator on all Inpatient claims. See Note below.

Note: This option is disabled for DRG grouper versions prior to 2008.

Effective date of the current contract rates

General Ledger code

Hospital service code

Facility’s ten-digit National Provider Identification (NPI) number required on all claims

Patient type assigned to the account: Inpatient/Outpatient

Payor code associated with the account.

Name of the insurance product

Provider’s tax ID number or ten-digit National Provider Identification (NPI) number required on all claims

Provider/specialty type used in conjunction with the National Provider Identification (NPI) number

The termination date of the contract, if any is present and the customer has requested it to be included

Any PDF files that are associated with the profile

Minimum activation date for service type definition tables. Only available when View Service Type Definition Details is selected.

Order in which the service types are displayed in the profile’s TAC

Option to display the definition details and/or the reimbursement terms for each service type in the profile

Indicates if the associated contract maintenance and negotiation information is displayed. When selected, the available information appears below the Profile Actions section

Indicates whether the complete details of the service type definition are displayed

Click to display the service type definitions using the selected display options.

Click to save the selected display options as your default settings.