Lesser of Provider Reimbursement Policy
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This policy governs how Network Health determines allowed reimbursement when a provider's billed charge is less than any contractual or fixed reimbursement rate; it applies to all lines of business and all Network Health products and affects participating providers and claims processing.
No material clinical or coverage changes in this revision.
Payment Determination Rules
Lesser-of payment criteria
Payment determination rules when a provider's billed charge is less than any contractual or fixed reimbursement rate:
ALL of the following
- Network Health will not reimburse providers in excess of their billed charges, regardless of any contractual and/or fixed rate methodology.
- Allowed reimbursement amount for each billed line = the lesser of: (a) the provider's billed charge for that line, or (b) the contractual and/or fixed rate.
Billing Lines and Allowed Amount Rules
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What Providers Should Know / Do
Reimbursement determination — lesser of billed charge or contractual/fixed rate
Network Health will determine the allowed reimbursement as the lesser of the provider's billed charge per line or the contractual and/or fixed rate; Network Health will not reimburse providers in excess of their billed charges.
- Allowed amount per line = the lesser of provider billed charge per line or the contractual and/or fixed rate.
- Network Health will not pay more than the provider's billed charge under any circumstances.
Terminology
OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.