Multiple Surgeries Sample Clauses
The Multiple Surgeries clause defines how benefits or payments are handled when a patient undergoes more than one surgical procedure during a single operative session. Typically, this clause outlines whether the insurer will pay the full benefit for the primary surgery and a reduced percentage for additional surgeries performed at the same time. For example, if a patient has two or more procedures, the first may be covered at 100% while subsequent ones are reimbursed at a lower rate. This clause ensures fair compensation for multiple procedures while preventing excessive billing for surgeries performed together, thereby managing costs and clarifying payment expectations for both providers and patients.
Multiple Surgeries. When a doctor performs more than one procedure in a day, there are rules that may reduce our allowance for the additional procedure. Our allowance may also include post-operative care and other procedures provided within specified time periods.
Multiple Surgeries. If more than one surgical operation is performed through a single incision or because of the same or related conditions, such multiple surgeries may be regarded as one operation and the benefit applicable under this segment shall be equal to the benefit for that one of the operations for which the largest amount is payable, provided this does not exceed the maximum amount specified in the Schedule of Benefits. If more than one surgical operation is performed on the same person through separate incisions because of unrelated conditions and such conditions result from the same injury, or such operations are performed within a twenty-four (241 hour period, the benefit applicable for such multiple surgeries shall be equal to the benefit for that one of the operations for which the largest amount is payable plus one-half of the benefit provided for each of the other operations, provided this sum does not exceed the maximum amount specified in the Schedule of Benefits. However. if more than one surgical operation is performed on the same person because of unrelated conditions and such operations are separated by a period of more than twenty-four
Multiple Surgeries. Requirements: QMACS needs to identify and process claims appropriately when multiple procedures are performed on the same date of service, whether such procedures are billed together or separately and with or without the appropriate modifier indicated by the provider of service. QMACS needs to be capable of paying modifier discounts in tiers according to the contracted amount (e.g. 2nd procedure at 50%, 3rd procedure at 25% and so on) by program/line of business. Such functionality may utilize the system global days table which indicates which procedures qualify for multiple surgery. Overview: - A new edit will be created to indicate that multiple surgeries were detected and NOT billed appropriately. - QMACS will evaluate the current claim and all historical claims for the member to find claims for the same date of service with the same provider. - If multiple procedures are found and modifier 51 is not used, fire the new edit. - In addition to firing the new edit, QMACS should apply the 51 modifier to all but the most expensive procedure performed on the same day. - By default, modifier 51 should be added to the least expensive procedure(s). The most expensive procedure is considered primary. However, in the event that a less-expensive procedure has already been paid, the remaining procedures should be changed to reflect the 51 modifier.
Multiple Surgeries. If more than one surgical operation is performed through a single incision or because of the same or related conditions, such multiple surgeries may be regarded as one operation and the benefit applicable under this segment shall be equal to the benefit for that one of the operations for which the largest amount is payable, provided this does not exceed the maximum amount specified in the Schedule of Benefits. SURGICAL OPERATIONS NOT CONTAINED IN THE SCHEDULE OF OPERATIONS. If the operation performed is not shown in the Schedule of Operations, Kaiser reserves the right to determine the amount of Surgeon’s Fee payable for such operation. An operation of comparable or equivalent gravity and severity will be used as a basis for the settlement, but not to exceed the maximum provided under this Contract.