FH® Allowed HCPCS Facility Launches in April

March 16, 2023

In April, FAIR Health is launching a new addition to our suite of FH® Allowed Benchmarks: FH® Allowed HCPCS Facility.

FH Allowed HCPCS Facility
The new FH Allowed HCPCS Facility will use actual allowed values—the amounts negotiated between insurers and providers participating in insurers’ healthcare networks—from commercial claims data. FH Allowed HCPCS Facility will provide benchmarks based on aggregated amounts allowed by plans and arrayed by Level II HCPCS codes for products, supplies and services billed by a facility and generally not included in CPT®1 codes. Where frequency thresholds are met, actual amounts for procedure code/geozip combinations will be used, while FH Healthcare Market Index™ relative values will be used to derive benchmarks where values do not meet frequency or validation thresholds.

FH HCPCS Facility
The new FH Allowed HCPCS Facility complements the existing benchmark FH® HCPCS Facility, which contains aggregated billed charges arrayed by Level II HCPCS codes for products, supplies and services billed by a facility and generally not included in CPT codes. The new product will allow clients to compare and use both FH HCPCS Facility and FH Allowed HCPCS Facility benchmarks to better meet their needs.

FH NSA Reference File
The allowed HCPCS facility data will also be added to another product, the FH® NSA Reference File, which provides median allowed amount values to support organizations affected by the federal No Surprises Act (NSA). The NSA requires plans to calculate patients’ cost-sharing responsibilities for certain surprise medical bills using the plan’s Qualifying Payment Amount (QPA). The QPA is the payor’s historic median contracted amount for each procedure code in each market and geographic area it covers. When payors have insufficient provider contracts to calculate the applicable median contract amount for a specific service, they must use an independent third-party database to calculate the QPA and determine the patient’s cost-sharing obligations. Plans can use FAIR Health data in the FH NSA Reference File to help calculate the QPA in these situations. In addition, the data may inform the plan’s selection of an initial payment amount to out-of-network providers, potentially reducing disputes and the need for arbitration. The data may also prove useful for all stakeholders in preparation for arbitration and dispute resolution.

FAIR Health President Robin Gelburd stated: “FAIR Health is pleased to include the new FH Allowed HCPCS Facility in our suite of benchmark products. It will enhance our existing offerings to healthcare stakeholders seeking an independent and robust reference point with which to further their goals.”

For more information, contact us by email at info@fairhealth.org or call us at 855-301-FAIR (3247), Monday through Friday, 9 am to 6 pm ET.

1 CPT © 2022 American Medical Association (AMA). All rights reserved.