Avidon Health, LLC
As of January 1, 2023, Avidon Health, LLC has transitioned to a self-funded health plan. While Avidon Health, LLC is the ultimate payer, the Plan is facilitated by the Third Party Administrator, SISCO Benefits. This is an open-access plan type, similar to an indemnity plan, giving the members the freedom to visit any provider they choose without reduced benefits for out-of-network providers.
How does this work?
The process is actually very simple. As a provider, you treat the patient and collect any applicable co-pay at the time of service. Medical claims are then submitted to SISCO Benefits and repriced by 6 Degrees Health.
Claims may be submitted to SISCO Benefits electronically, with the Payer ID: 44827
Claims unable to be submitted electronically can be mailed to:
PO Box 389
Dubuque, IA 52004
How will providers be reimbursed?
Facility & Physician providers will be reimbursed at the Allowable Charge, as described below.
“Allowable Charge” shall be determined, with respect to ProPlus Providers, by determining the lessor of:
1. Amount established by the ProPlus Provider negotiated agreement;
2. Specified Benefit Amount;
3. Gross billed charge made by the provider;
4. Usual, Customary and Reasonable payment for the same treatment, service, or supply; or
5. Prevailing fee charged in an area sufficient in size to obtain a representative cross-section of providers rendering such treatment, supply, or services for which the charge is made by Providers of similar skill and experience.
“Allowable Charge” shall be determined, with respect to non-ProPlus Providers, by the terms of the negotiated agreement, if one exists. If no negotiated agreement exists, the Allowable Charge shall be established by determining the lessor of:
1. Specified Benefit Amount;
2. Gross billed charge made by the provider;
3. Usual, Customary and Reasonable payment for the same treatment, service, or supply; or
4. Prevailing fee charged in an area large enough to obtain a representative cross-section of providers rendering such treatment, supply, or services for which the charge is made by Providers of similar skill and experience.
For Covered Charges rendered by a Physician or other professional provider, in a geographic area where applicable law dictates the maximum amount that can be billed by the rendering provider, the “Allowable Charge” shall mean the amount established by applicable law for that Covered Charge.
The Allowable Charges shall not include:
1. Charges for any items billed separately that are customarily included in a global billing procedure code in accordance with American Medical Association’s CPT® (Current Procedural Terminology) and/or the Healthcare Common Procedure Coding System (HCPCS) codes used by CMS;
2. Charges for billing errors including, but not limited to, upcoding, duplicate charges, and charges for services not performed;
3. Charges relating to clearly identifiable errors in medical care;
4. Charges the Plan Sponsor cannot identify or understand the item(s) being billed; or,
5. Charges identified based upon a medical record review and audit, which determines that a different treatment or different quantity of a drug or supply was provided.
Nothing in this section shall be construed to limit the Plan Sponsor’s discretion to deem a greater amount payable than the lesser of any of the above-referenced amounts. Furthermore, the Plan Sponsor is not obligated to consider all factors. In the event that the Plan Sponsor determines that insufficient information is available to identify the Allowable Charge for a specific service or supply using the listed guidelines above, the Plan Sponsor reserves the right, in its sole discretion, to determine any Allowable Charge amount for certain conditions, services and supplies using accepted industry-standard documentation, applied without discrimination to any Covered Person.
Subsequent to payment of the Allowable Charge by the Plan Sponsor, the Provider may seek additional payment from the Plan Participant (i.e. balance billing). Under these circumstances, the Plan Sponsor, in its sole discretion, may elect (but is in no instance required) to negotiate a Settlement of Outstanding Balance with the Provider to resolve the Plan Participant’s obligation. The Settlement of Outstanding Balance will be eligible for payment by the Plan in full.
Specified Benefit Amount
“Specified Benefit Amount” means the charges for services and supplies, listed and included as Covered Charges under the Plan, which are Medically Necessary for the care and treatment of Illness or Injury, but only to the extent that such fees do not exceed the Specified Benefit Amount. The determination that a charge does not exceed the Specified Benefit Amount include, but are not limited to, the following guidelines:
· 1.4 times the Medicare Allowed Amount for a Hospital facility, facility which is owned and operated by a Hospital, or an Ambulatory Surgery Centers;
· 1.4 times the Medicare Allowed Amount for Physician and other eligible providers;
· 100% of the Organ Procurement Organization’s invoice cost; and
· 100% of the National Marrow Donor Program’s invoice cost.
Under the Plan, the “Medicare Allowed Amount” shall not include an adjustment for Disproportionate Share Hospitals or outpatient outlier adjustments. If the Plan cannot determine the Medicare reimbursement for like or similar services because the medical claim form (UB04 or HCFA1500) does not contain all the necessary information, then the Plan shall make a reasonable estimation based on available industry data of the missing information to accommodate prompt payment to the billing provider.
If the Plan makes a reasonable estimation of missing information, then the Provider may resubmit a corrected claim with the information required to calculate the Medicare reimbursement. If the Provider submits a corrected claim, then the Plan Sponsor may recalculate the Specified Benefit Amount to adjust payment to the Provider to reflect the information on the corrected claim.
If you have questions regarding the plan benefit, or want an estimate of the expected reimbursement, you can call 6 Degrees Health Provider Services at (888) 615-6398.
The content of this website is meant to provide general information on plan benefits and terms. The Summary Plan Document used by the Plan is the definitive statement of Plan terms and benefits. If there is a conflict between the information contained on this website and the contents of the Summary Plan Document, the Summary Plan Document controls. None of the content on this website should be construed as a guarantee of benefits.