For Healthcare Providers:

Repricing Guidelines

Follow these recommendations and guidelines when submitting claims:

Billing for Anesthesia Services

  • Submit claims with applicable ASA codes
  • Report time in minutes; we will convert billed time to 15-minute units
  • We will not process claims with surgical CPT codes that have an ASA crosswalk
  • CPT codes 00100-01999 will be reimbursed on the ASA scale
  • CPT codes 10020-99499 will be reimbursed as listed in the physician fee schedule

Clean Claim Definition

Midlands Choice provider contracts define clean claims as those that are submitted on a standard claim form (837, CMS-1500 or UB-04) with all reasonably necessary information, completed according to CPT-4, ICD-10 or HCPCS coding standards, that do not require additional information for processing.

Modifiers

Bill normal charges. We will adjust charges according to the fee schedule.

Usual, Customary and Reasonable (UCR)

Midlands Choice does not incorporate a UCR database during repricing. Payers' UCR provisions do not apply to Midlands Choice claims unless:

  • the fee schedule allows application of UCR to certain CPT codes, or
  • the claim is for covered benefits not listed in the fee schedule (e.g. vision hardware)

Special Reimbursements

  • Unlisted CPT and HCPCS codes receive a percentage discount, negotiated in the provider's contract.
  • Transplant reimbursement rates vary by contract.

Timely Filing

Midlands Choice contracts require claims to be submitted within six months from the date of service. Claims filed after this time frame may be rejected by the payer.