Merged in bugfix/carveout_base (pull request #814)
bugfix/carveout_base to main * updated base covered services Approved-by: Katon Minhas
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Katon Minhas
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@@ -3,7 +3,7 @@
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"description": "Valid carveout types and descriptions"
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},
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"mapping": {
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"BASE_COVERED_SERVICES": "Base reimbursement rates that form the foundation of the payment structure. Describes foundational payment methodologies for standard covered services, including primary coverage determinations. This refers to payment methodologies that establish the fundamental reimbursement structure, not exceptions or adjustments to it. Examples: 'covered services' 'Covered Services not included...', 'services primary to Medicare', etc.",
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"BASE_COVERED_SERVICES": "Base reimbursement rates that form the foundation of the payment structure. Describes foundational payment methodologies for standard covered services, including primary coverage determinations. This refers to payment methodologies that establish the fundamental reimbursement structure, not exceptions or adjustments to it. Examples: 'covered services' 'Covered Services not included...', 'services primary to Medicare', etc. A term remains BASE_COVERED_SERVICES even when it applies only to a specific service category or product, so long as it defines the standard way those services are paid and does not create an exception or adjustments to another payment methodology.",
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"PAYMENT_CARVEOUT": "Describes payments for specific services, procedures, level designations ('Secondary', 'Primary', 'Tertiary', etc), or specific DRG or codes or specific ages('Child','Adolescent','Adult', etc) that are carved out from the base/foundational payment methodology with distinct payment terms. These are exceptions or specialty payments that differ from the payments for standard/ base services. Examples include 'Radiology covered services', 'Anesthesia covered services', 'Pharmaceuticals', 'HEMATOCRIT (CPT CODE: 85014)', and level designations such as 'Secondary', 'Primary', 'Tertiary', 'Progressive Care'. Do NOT classify as payment carveout if the service represents a foundational coverage determination (such as primary payer methodologies in dual products) rather than a different payment to standard one.",
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"UNLISTED_CODE": "Describes payments for codes that are not listed on a fee schedule. This is similar to DEFAULT_TERM. Only populate with Y if the Service or Methodology specifically mentions Codes.",
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"ADDITION": "Describes payments that include a supplemental amount added to or above the base reimbursement rate. Populate with Y if the Methodology describes any additional payments, supplemental amounts, or add-on fees beyond the standard reimbursement.",
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