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On January 1, 2012, Ambulatory Payment Classifications (APC) reimbursement
was added to the Hospital Agreement (Agreement) for certain Independence
products. According to that Agreement, the APC Grouper/Pricer and Fee Schedules
published and distributed by the Centers for Medicare & Medicaid Services
(CMS) are used to determine reimbursement. The reimbursement amount is the
product of the CMS APC Pricer amount (or fee schedule amount) and the CMS
Pricer Adjustment Factor.
In the event CMS makes updates to APC Grouper/Pricer and/or Fee Schedules,
Independence will update the APC Grouper/Pricer within 60 days* of CMS
publishing such updates. The parties agree, however, that retrospective changes
made by CMS shall not apply.
If you have a concern regarding the way your claims are reimbursed, please
use your applicable version of the CMS Outpatient Prospective Payment System
(APC Pricer) to verify proper compensation.
If discrepancies remain, or if you have any questions, please contact your
Network Coordinator.
* The time frame may vary. Please refer to your specific
Agreement with Independence.
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