Sec. 54.9816-6 Methodology for calculating qualifying payment amount.
(a) For further guidance see § 54.9816-6T(a) introductory text through (a)(17).
(1) – (17) [Reserved]
(18) Downcode means the alteration by a plan or issuer of a service code to another service code, or the alteration, addition, or removal by a plan or issuer of a modifier, if the changed code or modifier is associated with a lower qualifying payment amount than the service code or modifier billed by the provider, facility, or provider of air ambulance services.
(b) – (c) For further guidance see § 54.9816-6T(b) and (c).
(d) For further guidance see § 54.9816-6T(d) introductory text through (d)(1)(i).
(1) [Reserved]
(i) [Reserved]
(ii) If the qualifying payment amount is based on a downcoded service code or modifier–
(A) A statement that the service code or modifier billed by the provider, facility, or provider of air ambulance services was downcoded;
(B) An explanation of why the claim was downcoded, which must include a description of which service codes were altered, if any, and a description of which modifiers were altered, added, or removed, if any; and
(C) The amount that would have been the qualifying payment amount had the service code or modifier not been downcoded.
(iii) – (v) For further guidance see § 54.9816-6T(d)(1)(iii) through (v).
(2) For further guidance see § 54.9816-6T(d)(2).
(e) – (f) For further guidance see § 54.9816-6T(e) and (f).
(g) Applicability date. The provisions of this section are applicable for plan years beginning on or after January 1, 2022, except that paragraph (a)(18) of this section regarding the definition of the term "downcode" and paragraph (d)(1)(ii) of this section regarding additional information that must be provided if the qualifying payment amount is based on a downcoded service code or modifier are applicable with respect to items or services provided or furnished on or after October 25, 2022, for plan years beginning on or after January 1, 2022.
[Added by T.D. 9965, 87 FR 52618-52655, Aug. 26, 2022.]
