State prevailing rates are fees for Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes for which the Defense Health Agency (DHA) has not established rates or fees. Please note that the CHAMPUS Maximum Allowable Charges (CMAC) take precedence over state prevailing rates.
Once you've identified the rate associated with the claim's process date, verify that the claim's date of service falls between that rate's effective date and expiration date.
Procedure code: 74300
Provider class: 001
Modifier: 00
Date of service: 8/1/2020
Claim processed date: 10/15/2020
Rate: $441
Explanation: Since the processed date was 10/15/2020 and it must fall AFTER the rate's revision date, we must refer to the row highlighted above. If the claim's date of service falls within this rate's effective date and expiration date, then this is the accurate rate for the claim.
Procedure code: 74300
Provider class: 001
Modifier: 00
Date of service: 8/1/2020
Claim processed date: 8/31/2020
Rate: $824
Explanation: Since the processed date was 8/31/2020 and it must fall AFTER the rate's revision date, we must refer to the row highlighted above. If the claim's date of service falls within this rate's effective date and expiration date, then this is the accurate rate for the claim.
Procedure code: 74300
Provider class: 001
Modifier: 00
Date of service: 11/1/2019
Claim processed date: 12/8/2019
Rate: Billed charge
Explanation: Since the processed date was 12/8/2019 and it must fall AFTER the rate's revision date, we must refer to the row highlighted above. This claim's date of service falls after this rate's expiration date, meaning none of the rates above apply.
What do the table columns mean?
Procedure code: CPT/HCPCS code
State: the state for which the rate is calculated
Provider class: the provider’s level of education or type of certification (i.e. M.D., D.O., LPN etc.)
Modifier: the CPT modifiers (also referred to as Level I modifiers) are used to supplement information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician; code modifiers help further describe a procedure code without changing its definition
Effective date: the beginning date of service applicable to the record
Expiration date: the through date of service applicable to the record
Revision date: the date the state prevailing rate was last reviewed or revised
Rate: the fee per unit for the CPT/HCPCS code
Active: A "Y" value indicates that the rate is active; "N" value indicates the record is not currently active
Why are there multiple rows for one procedure code?
The state prevailing rate table provides the current rate as well as historical rates. Lines may also be added for multiple provider classes and/or modifiers.