EDIT - Incentive Fee

The Incentive Fee is designed as a payment to Providers for specific performance.  This performance is typically driven by the codes submitted by the Provider in the DUR/PPS Level of Effort (474-8E).  Other qualifiers may be used to qualify if the claim is subject to an Incentive Fee through Adjudication Rule Criteria.

Incentive Fees are only effective for Paid claims.  Reversal claims will have any applied Incentive Fees reversed.

The Incentive Fee is one of the unique Edits within the platform.  The typical edit is used and no additional edits of the same type are additionally applied.  For instance, if an AGE Limit edit is used, no other age limit edits are checked.  This will be reviewed in the Incentive Limitations section.

Edit Name is the unique name for the edit.

Message Group is the assigned Message group to be captured each time the edit is used.

Incentive Limitation

Multiple Incentive Edits can be called and applied during claim processing. The Incentive Limitation sets controls how many incentive fees can be applied to a claim.

There is no limitation on the number of Incentive Fee edits that can be applied to a claim.  To control this, the Incentive Fee may be allowed to:

• Apply Incentive Fees:  If the EDIT is established with this limitation, the Incentive Fee will be calculated and applied.  The process then looks for the next Incentive Fee that satisfies the adjudication rule.
• Apply Incentive Fee Then Ignore:  If this limitation is selected, the incentive fee for this edit will be used but any additional Incentive Fees will be ignored.
• Ignore all Incentive Fees:  If this limitation is selected, the incentive fee for this edit will be ignored and all ensuing Incentive Fee edits will be ignored.

Incentive Basis

The Incentive Basis defines how the Incentive Fee will be calculated.

• Amount Submitted in Claim by the Provider:  The Provider submitted Incentive Amount Submitted fee (438-E3) on the claim.
• Amount Calculated in Edit (INGR + DISP) based on PROVIDER if on PROVIDER NETWORK record and on PLAN if on PLAN Adjudication Rules.

Incentive Method

The Incentive Method allows control over how the incentive fee is calculated.

• $ then %:  Takes the total cost of the Rx plus the $ Rx, then its sum is multiplied by the % Fee.
• % then $:  Takes the % Fee times the Cost and then adds the fixed amount
• Lessor Of:  Compares the $ RX fee to the % Fee calculation and uses the lowest amount
• Higher Of:  Compares the $ Rx fee to the % Fee calculation and uses the higher amount

Cost Sharing Method

The Cost Sharing Method identifies who has the financial liability of the approved Incentive Fees.  The fee can be paid entirely by the Plan or entirely by the Member.

If the Incentive Basis used is Amount Calculated in Edit, the Flat Amount ($), % Amount, Incentive Fee Min and Incentive Fee Max are available.