Schedule M2 Claims Repricing Active FY2025.xlsx

Document Cover

Group: Active

Claim Paid Period: 01/01/2025 - 12/31/2025

Table of Contents

2 Inpatient

3 Residential Treatment

4 Day Treatment

5 Outpatient

6 Intensive Outpatient Program (IOP)

Bidder must not alter columns A through J or sort the information

Definitions Definitions:

· Inpatient Hospital Services – Services related only to the hospital or free standing facility charges of an acute inpatient stay.

· Residential Services – Services related only to the Non-hospital or free standing facility charges of a longer term live-in treatment facility.

· Day Treatment Services – Services related only to the delivery of day treatment regardless of setting.

· Outpatient Services – Psychiatric, psychological and substance abuse treatment expenses for providers who have direct contact with a patient. Includes medication management, psychological and substance abuse treatment from qualified providers.

· Intensive Outpatient Program Services – Services provided for 2-3 hours at a time, several days a week in a non-office setting.

· Professional Services – Provider services while the member is inpatient or in residential treatment (higher level of care).

· Eligible Billed Charges – Defined as the amount billed by the provider for benefits eligible for payment under the benefit contract. The Eligible Billed Charges exclude any duplicate claims or disallowed benefits. Claims that are not processed to determine the payment to be made to the provider (e.g. COB claims, bundled/unbundled charges) are excluded from Eligible Billed Charges.

· TIN – Provide the TIN and name of the specific provider rendering the service, even if the physician is part of a larger group practice.

· Provider City, State and Zip Code – Provider information should align with place of service and not billing address

· Allowed Amount – Represents the negotiated reimbursement amount for covered services before member cost sharing (e.g., deductible, copayment, or coinsurance). Amount to be populated by bidders which is based on the 01/01/28 fee schedule.

&F&A

Inpatient

IC, OC, IX, OX