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DATE: January 13, 202019

TO: Santa Barbara Select IPA Participating Providers

FROM: Contracting & Claims Departments

RE: Fee Schedules & Payment Policies – 2019 2020 Update

The following information concerning Santa Barbara Select IPA’s fee schedules and payment policies is provided to you in order to satisfy the requirements of the Claims Settlement Practices and Dispute Resolution Mechanism Regulations (CA Code of Regulations, Section 1300.71).

For services eligible for fee-for-service payment under the terms of your provider contract with Santa Barbara Select IPA, the terms of the contract control the amount of payment. Please refer to your contract for more detailed information on the reimbursement method and rates that apply to you. Where inconsistent with the contract itself, (e.g., the contract states exceptions, case rates or per visit rates) the contract supersedes the below general description.

Payment Policies: The following describes our general payment policies. These rules apply unless stated differently in your contract. Our claim payment policies follow industry standards as defined by The Centers for Medicare and Medicaid Services (CMS), except as stated otherwise below or in your contract:

Medicare Guidelines. Santa Barbara Select follows the Medicare Correct Coding Initiative and applies CMS guidelines to the re-bundling of procedure codes, as well as the application of modifiers for the payment of services involving multiple procedures, bilateral procedures, co-surgeons, and surgical global periods. Santa Barbara Select does not adhere to the typical claims handling practice of Medicare carriers who automatically pay codes as billed. Santa Barbara Select reserves the right to occasionally require chart documentation in advance of payment based on its reasonable judgment that codes or modifiers submitted might not be accurate.

Assistant Surgeon. For assistant surgeon services, it is our policy to multiply the applicable contracted rate by a factor of twenty percent (20%).

Coding of Claims. Santa Barbara Select references the standard coding structure based on the AMA’s Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS), and ICD-9 Diagnosis coding, for basic coding and description of services provided. Santa Barbara Select shall use its best efforts to update the coding structure on an annual basis.

Coding Levels Payable. For services requiring authorization, we pay based on the level of care authorized, provided the services actually rendered equal or exceed the level authorized. If a lower level service is actually provided, the Provider must use the accurate code for the services rendered. In the event the provider bills a more highly valued code, we will accept higher codes (e.g., a higher consult code for an authorized consultation) if, a) it is medically justified, b) generally consistent with the scope of services authorized and, c) the documentation is submitted with the claim. We will not pay an Evaluation & Management code above the middle tier unless the foregoing justification is provided. The “middle tier” code is considered to be the “level 3” code for five tier ranges such as 99211 - 99215 (e.g., 99213) or the “level 2” code for three tier ranges such as 99221 – 99223 (e.g. 99222) and the lower tier in two tier ranges such as 99238 – 99239 (e.g. 99238).

Fee Schedules: If your contractual fee schedule is based on a percentage of the “Medicare Fee Schedule (e.g., 80% of Medicare Allowable) claims are processed at the contractual percentage of the current fee schedule which is loaded to Santa Barbara Select’s claims system at the time of payment. As of January 1, 2017, the Medicare Physicians Fee Schedule no longer has Area 99 which was the prior locality for Santa Barbara County and other parts of California. Santa Barbara County is now its own area designation which is Area 74. If your contract references Area 99 as a basis for compensation rates, we interpret this to mean Area 74, as of 1/1/17. If your contract does not reference area 99 or specifies the area in which you provide services, then we will utilize the applicable Medicare area for your service location. Santa Barbara Select uses best efforts to implement annual changes to Medicare Fee Schedules as soon as possible after the change is effective with CMS. To view the 2019 2020 Medicare Physicians Fee Schedule for Area 74, please click here:

If the Medicare Fee Schedule has no rate for a particular service, and your contract does not specify a default payment method for such instances, Santa Barbara Select will determine a fee allowance based on either 1) the Medicare equivalent value for such service using the MPFS method or 2) a reasonable rate considering appropriate other factors.

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