Computable Contract Library
Purpose
Create and maintain open standards to:
- Support the evolution of complete and accurate price transparency disclosures
- Serve as a resource for contract standardization across the healthcare industry
- Facilitate innovation around claims pricing
What is a Computable Contract Reimbursement method?
It is a standard, re-usable formula for pricing a healthcare claim that combines industry standard provider-payer payment terminology with a common claims ontology to arrive at the claim allowed amount represented in a dollar format.
Reimbursement Formulas
Some of these methods are already required by the Hospital Price Transparency (HPT) and Transparency in Coverage (TIC) Rules. Others are recommended to cover a broader scope of reimbursement scenarios.
Single all-inclusive payment amount per case based on a fixed contractual amount
Computable Formula
Common Sites of Care
- Inpatient Hospital
- Outpatient Hospital
- Ambulatory Surgical Centers (ASCs)
Common Contract Provisions
- Inpatient Surgery Carveouts
- Outpatient Surgery
- Outpatient Emergency
Single all-inclusive payment per case, with an additional payment per day if the visit length exceeds a specified attachment period
Computable Formula
Criteria
Rate Calculation
Criteria
Rate Calculation
Common Sites of Care
- Inpatient Hospital
Common Contract Provisions
- Maternity
- Inpatient Surgery
Single all-inclusive payment amount per case, referring to an external list of payment weights outside of the contract
Computable Formula
Common Sites of Care
- Outpatient Hospital
- ASC
- Professional
Common Contract Provisions
- Clinical Laboratory
- High Cost Pharmaceuticals
- Outpatient Services
Single all-inclusive payment amount per case, referring to an external list of payment weights outside of the contract
Computable Formula
Common Sites of Care
- Inpatient Hospital
- Outpatient Hospital
- Ambulatory Surgical Centers (ASCs)
Common Contract Provisions
- Inpatient Surgery Carveouts
- Outpatient Surgery
- Outpatient Emergency
A percentage-based rate that is triggered by a specific service, but which applies to the entire claim
Computable Formula
Common Sites of Care
- Applied Universally
Common Contract Provisions
- High Cost Drug Carve-out
- All Other Services
- Global Rate (all services)
When a specified threshold is met, the entire claim is repriced under a different pricing methodology
% of Charges Computable Formula
Criteria
Rate Calculation
Scope
Entire claim paid at Stop Loss rate
Per Diem, Charge Threshold
Criteria
Rate Calculation
Scope
Entire claim paid at Stop Loss rate
Per Diem, Day Threshold Computable Formula
Criteria
Rate Calculation
Scope
Entire claim paid at Stop Loss rate
Regular contract rates are paid until a specific threshold is met; subsequent charges or days are repriced under a different pricing methodology
Per Diem after Attachment Day Computable Formula
Criteria
Rate Calculation (For days after attachment day)
Scope
Days through attachment day: paid at contract rates
Days after attachment day: paid at stop loss per diem
% of Charges after Attachment Day Computable Formula
Criteria
Rate Calculation
Scope
Days through attachment day: paid at contract rates
Days after attachment day: paid at Stop Loss %
Service Date % of charge with NTE Per Diem Computable Formula
Criteria
Rate Calculation
Days through attachment day: paid at contract rates
Days after attachment day: percentage of daily charges, with a daily not-to-exceed cap
Per Diem after Day Threshold Computable Formula
Criteria
Rate Calculation
Days through attachment day: paid at contract rates
Days after attachment day: paid at stop loss per diem
Regular contract rates are paid on the claim, but if a specific threshold is met an additional payment amount is made
Excess Charges Add-on Computable Formula
Criteria
Rate Calculation
Scope
Entire claim paid at contract rates, plus add-on payment
Excess Days Add-on Computable Formula
Criteria
Rate Calculation
Excess Days Add-on using Average Length of Stay Computable Formula
Criteria
Rate Calculation
Scope
Entire claim paid at contract rates, plus add-on per diem
A cost-based outlier mechanism used in Medicare IPPS reimbursement that generates an add-on payment for high-charge claims
Computable Formula
Common Sites of Care
- Inpatient Hospitals
Common Provisions
- % of IPPS (MS-DRG)
Scope
Entire claim paid at contract rates, plus add-on payment
Variables Glossary
The terms from the formulas above are outlined in the table below
| Term | Definition |
|---|---|
| Claims Variables | |
Line Item Charge Amount | Line Item Charge Amount from the 837/835 |
Total Revenue Code Charges | The sum of all Line Item Charge Amounts from the 837/835, grouped by Revenue Code |
Total Claim Charges | Total Claim Charge Amount from the 837/835 |
Total Service Date Charges | The sum of all Line Item Charge Amounts from the 837/835, grouped by Revenue Code |
Length of Stay | Calculated as Statement Through Date - Statement From Date on the 837/835 |
Service Line Units | Line Item Quantity from the 837, or Units of Service Paid from the 835 |
| Fee Schedule Variables | |
Base Rate | A contractually-defined rate that is multiplied by the variable weights from the fee schedule |
Weight | A relative weight from the fee schedule for the billed code (MS-DRG, APC, etc.) |
Multiplier | An optional contractual percentage applied to the Base Rate * Weight calculation (e.g., "110% of the fee schedule amount") |
| Contract Variables | |
Total Eligible Charges | The sum of claim charges eligible for payment under a specific contract provision |
Charge Threshold | A contractually defined dollar threshold used to trigger stop loss or outlier provisions |
Day Threshold | A contractually defined day-count threshold used to trigger stop loss or outlier provisions |
Stop Loss % | A percent of charge rate associated with a stop loss provision and applied to the eligible charges |
Stop Loss Per Diem | A per-day rate used in stop loss calculations and applied to any days beyond the attachment day |
Attachment Day | The day that a claim exceeds a specific threshold (either via a charge or day threshold) |
AMLOS | Arithmetic Mean Length of Stay, as defined by CMS in MS-DRG files |
GMLOS | Geometric Mean Length of Stay, as defined by CMS in MS-DRG files |