State prevailing rates (or state fees), 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.
Please refer to the examples below for more guidance.
Example 1: Active rate is applicable
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.
Example 2: Active rate is NOT applicable
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.
Example 3: No rates are applicable
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.