doczyai-pipelines/fieldExtraction/constants/mappings/valid_carveouts.json

{
    "metadata": {
        "description": "Valid carveout types and descriptions"
    },
    "mapping": {
        "BASE_COVERED_SERVICES": "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:\n- 'covered services'\n- 'Covered Services not included in the Service Categories in Table 1 shall be reimbursed at 100% of the Medicare fee schedule'\n- Primary coverage methodologies in dual products (e.g., 'services primary to Medicare', 'services primary to Medicaid')\n- Base reimbursement rates that form the foundation of the payment structure",
        "PAYMENT_CARVEOUT": "Describes payments for specific services, procedures, level designations, or specific DRG or codes that are carved out from the base/foundational payment methodology with distinct payment terms. These are exceptions or specialty payments that differ from the standard approach. Examples include 'Radiology covered services', 'Anesthesia covered services', 'Pharmaceuticals' and 'HEMATOCRIT (CPT CODE: 85014)'. 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 true exception to standard payment.",
        "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.",
        "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.",
        "TRIGGER_CAP": "Describes the payments that trigger a complete shift to a new payment methodology after a defined quantitative threshold is reached. Unlike supplemental payments, this fundamentally changes how reimbursement is calculated beyond the threshold. Valid thresholds can be based on dollar amounts, number of days, visits, units, or other measurable metrics (but not qualitative thresholds, e.g., 'where there is no Marketplace Medicare Rate'). Look for language indicating a clear change in the payment methodology when a defined quantitative threshold is exceeded, such as 'when charges exceed X, pay Y', or 'after 3 days, payment changes to $1,200 per diem'. Do not classify outlier threshold reimbursements or stop-loss provisions as TRIGGER_CAP eventhough they may share similar characteristics.",
        "NEVER_EVENT": "Indicates that Never Events (e.g. sepsis acquired while inpatient) will not be covered. This may be phrased as 'no liability' or 'no payment'.",
        "EXPERIMENTAL_INVESTIGATIONAL": "Describes payments for experimental and investigational procedures.",
        "NOT_MEDICALLY_NECESSARY": "Describes payments for procedures deemed not medically necessary (or medically unnecessary)",
        "BUNDLED_CODES": "Indicates that payment for bundles of codes shall be at a reduced rate.",
        "MULTIPLE_PROCEDURE_REDUCTIONS": "Describe cases where payment terms apply to multiple or subsequent procedures or surgeries. It contains language indicating reduced payment for second and subsequent procedures, such as: 'multiple procedure reductions', 'second and subsequent deliveries' or similar terms that imply payment adjustments for multiple procedures performed during the same encounter.",
        "TECHNICAL_COMPONENT": "If Modifier TC (technical component) is present.",
        "PROFESSIONAL_COMPONENT": "If Modifier 26 (professional component) is present.",
        "DIAGNOSTIC_PROCEDURES": "Describes payments for diagnostic procedures.",
        "READMISSIONS": "Describes payment for subsequent admission with the same diagnostic category of codes as the initial admission.",
        "DEFAULT_TERM": "Indicates whether this service/methodology serves as a default/fallback payment rate when no other payment methods mentioned anywhere in the contract apply. The default/fallback/'end-of-the-line' payment rate may be a lower rate, often based on billed charges. It may be specific to certain services or applicable to all services. Do not classify as default if:\n- The methodology is the primary/base reimbursement approach, even if defined by exclusion\n- No default/fallback language is present\n\nExamples: \n- 'For any services not specifically listed in Exhibits A-D, reimbursement shall be 50% of billed charges.' \n- 'If there is no payment rate under the Medicare Fee Schedule, [alternative rate applies].'"
    }
}