Provider contract management that gives the rate in force on the date of service, cited to the contract page
The right rate or clause in seconds, cited to the contract page that sets it.
See one case, screen by screen ↓It is how a plan keeps provider agreements, amendments, fee schedules and payment policies in a form claims, dispute and network staff can use — and how it makes sure claims pay what was signed. Provider Contract Management answers any rate or clause question as a rate card for the date of service, cited to the contract page, and checks every paid claim against it each night.
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Every in-network claim is paid under a provider agreement: a base agreement, a stack of amendments, fee schedule exhibits written as a percentage of a Medicare schedule for a stated year, and payment policies for multiple-procedure reductions, modifiers and prompt-pay interest. The rate for one claim depends on the provider, the code, the setting and the date of service — which amendment was in force that day. Claims examiners, dispute analysts and provider service reps answer it by opening PDFs and reading them in effective-date order.
The claims system’s rate setup is keyed by hand from the same PDFs. When an amendment is signed but never loaded, every claim pays the old rate until the provider’s revenue cycle team writes in. Underpayments become disputes, reprocessing and prompt-pay interest; overpayments become recoveries that strain the relationship. Both are found late, or not at all.
Estimated split for one underpayment dispute, in hours of the analyst’s and configuration team’s time, by hand and with the solution.
Five specialist agents read the contracts, build the rate card and check every paid claim against it; the dispute analyst decides and signs.
Brightwater Orthopaedic Partners billed a total knee arthroplasty, CPT 27447, for a date of service of 14 August 2026. Cedar Valley Health Plan paid it $1,514.00. Here is what happens next, screen by screen, in the working solution.
Renata fills four slots: Brightwater Orthopaedic Partners, 27447, 14 Aug 2026, facility · locality 03. The card answers $1,726.00: the 2026 Medicare physician fee schedule amount of $1,380.80 × 125%, set by Amendment 3 §2.1 on page 4, effective 1 Jul 2026. Four signed entries are in force; one draft is ignored. Multiple-procedure, assistant-surgeon, global-period and prompt-payment terms sit beside it, each with its source.
How this card was built — 3.6 s: contract reader, rate resolver, payment policies, paid-claims checker, rate setup auditor. “Every figure opens its page.”
Under the rate sits the paid claim: 2026-0814-55102, member J. Marlow, billed $4,850.00, paid $1,514.00 on 2 Sep 2026 — $212.00 under the contract rate. The cause is named: rate setup row BOP-PROF-B still reads “118% of 2024 schedule”. 47 claims like it since 1 Jul 2026, $8,249.62 under; prompt-pay interest on this claim is $2.65 if it is reprocessed by 14 Oct.
Amendment 4, a bundled knee and hip episode rate of $14,900, is on the ledger as “Draft — not applied.”
The amendment ledger stacks the base agreement and Amendments 1 to 4 by effective date. Renata drags the date to 20 Jun 2026: the rate falls to $1,514.00, Amendment 3 turns “Not yet in force” and the base agreement’s Exhibit B — 118% of the 2024 schedule, “the year is fixed” — sets the rate again. That is exactly what rate setup still pays.
“Set by Amendment 3 · §2.1 · page 4” opens the signed amendment with §2.1, §2.2 and the effective-date clause highlighted, signed on 18 Jun 2026 by Priya Nandakumar for the plan and Dr. Elena Varga for the group. Margin notes show the arithmetic, that the schedule year moves each 1 January, and that the term applies by date of service, not by paid date.
“Effective by date of service — claims with service on or after 1 Jul 2026 — not by paid date.”
Every paid claim is compared with its rate card each night: 96,214 claims in 90 days, tolerance $5.00 or 1%. 573 are off contract at 8 providers — $88,503.86 under, $9,223.98 over. For Brightwater the rate setup auditor names the cause and lists the 47 claims across six surgical codes, ready to send to reprocessing.
“Agents never adjust a claim — reprocessing is released by a person.”
Brightwater’s revenue cycle team files DSP-2026-1187 on 22 Sep, asking for $1,726.00 with interest. The dispute opens with the rate card, what reprocessing pays — $212.00 + $2.65 on this claim, $8,249.62 + $96.18 on all 47 — and a drafted response that upholds it under Amendment 3 §2.1 and Section 7.4, with a citation on every statement.
“We have also identified 46 further claims paid at the earlier rate since 1 July and will reprocess them with this one, without a further dispute from you.”
Renata reads the draft and signs. In one step the response goes to Brightwater through the provider portal with three cited pages attached, reprocessing is released for 47 claims — $8,249.62 + $96.18 interest — and a change request for row BOP-PROF-B goes to Diane Castellanos.
The rate setup auditor reads 14,880 setup rows against 2,418 agreements and finds 8 that differ from the signed terms. Each change request names the row, the change, the source page and the claims it corrects — and is test-priced on five sample claims before it reaches Diane. The auditor never changes setup itself.
“Repriced 5 sample claims — all match the rate card.” Waiting for Diane Castellanos.
For negotiation Priya compares Brightwater with Summit Ridge Orthopedics and Kestrel Bone & Joint Clinic on eight codes, each cell the rate in force on 14 Aug 2026 under that group’s own agreement. For 27447: $1,726.00, $1,656.96 and $1,795.04.
“For negotiation: Kestrel’s surgery rate is 5 points above Brightwater’s.”
$97,727.84 paid off contract in 90 days, by cause — an amendment signed but never loaded, last year’s schedule still in setup, a payment policy revision missed. 1,846 rate cards asked October to date, a median 9 s to a cited rate, and 31 of 31 disputes answered on time this quarter.
The same knee replacement claim, seen by the five people who carry it — what their day looked like, and what it looks like now.
Five specialist agents read the contracts, build the rate card and check every paid claim against it; the dispute analyst decides and signs.
Reads every agreement, amendment, fee schedule exhibit and payment policy into rate terms — codes, basis, percentage, schedule year, fixed or updating — each with its page and paragraph.
Builds the rate card: stacks the signed terms in force on the date of service, applies the schedule year, locality and payment policies, and shows the arithmetic and the governing page.
Each night compares every paid claim with its rate card, flags gaps above tolerance with their direction and cause, and looks back to the term’s effective date to find every claim alike.
Reads the claims system’s rate setup row by row against the signed contract terms, writes the exact change with its source page, and test-prices five sample claims.
Drafts the written response to a provider dispute: recommends uphold or deny, cites each provision, computes interest under the agreement and names other claims with the same cause.
Signs responses; configuration lead approves setup changes. The agents propose; a named person decides.
Ask for any rate or clause by provider, code and date — every answer opens the page that sets it.
Why was the Brightwater knee claim paid $212 short?
Claim 2026-0814-55102 (27447, service 14 Aug 2026) was paid $1,514.00, which is 118% of the 2024 schedule under Exhibit B. From 1 Jul 2026 Amendment 3 pays codes 20000–29999 at 125% of the current-year schedule — $1,726.00. Rate setup row BOP-PROF-B was never updated, so the claim went out $212.00 under.
Find every Brightwater claim paid at the old rate since 1 July
47 claims were paid at the Exhibit B rate after Amendment 3 took effect on 1 Jul 2026, across six surgical codes — $8,249.62 short in all, plus $96.18 prompt-pay interest. Twelve are total knee replacements at $212.00 each, ready to send to reprocessing.
Compare Brightwater’s surgery rates with the other two orthopaedic groups
On 14 Aug 2026 Brightwater pays surgery at 125% of the current-year schedule; Summit Ridge Orthopedics at 120% and Kestrel Bone & Joint Clinic at 130%. For 27447 that is $1,726.00, $1,656.96 and $1,795.04.
Draft the response to dispute DSP-2026-1187
The response is drafted and waiting for your signature. It upholds the dispute under Amendment 3 §2.1, pays $212.00 with $2.65 interest under §7.4, and tells the provider we will reprocess the other 46 claims without a further dispute.
13 screens from the working solution, on its sample data. Pick one to see it large.
What Cedar Valley Health Plan decides — the agents follow these, from the next nightly check.
| Setting | Default | Choose from |
|---|---|---|
| Tolerance — gaps below are not flagged | $5.00 or 1%, whichever is greater | Any amount or percentage |
| Check runs | Nightly at 02:00 on the day’s paid claims | From the paid-claims file |
| Look-back on a new finding | To the effective date of the term | Finds every claim alike |
| Drafts and future amendments | Never applied | Fixed rule |
| Approves rate setup changes | Diane Castellanos, rate configuration lead | Any named approver |
| Second approval for reprocessing over | $25,000 · Priya Nandakumar | Any amount, any named approver |
| Interest on late or short payment | 1.5% a month | State rule where higher |
| Dispute response · provider dispute window | 30 days from receipt · 180 days from remittance | Clock on every dispute · window per agreement §7.6 |
Every figure is labelled: a target the solution is built to, an estimate, a typical published result, or a proven one.
“demo” = seen in the working solution, on its sample health plan data · “target” = the design goal, measured in the live solution · “estimated” = our estimate · “typical” = published figures (HHS-OIG OEI-09-18-00260, 2022 — 18% of denied payment requests met Medicare and plan billing rules, with system processing errors among the causes; CMS No Surprises Act IDR reports — 394,140 out-of-network payment disputes initiated in July 2026). People, plans and providers named on this page are fictional — characters and sample data in the working solution.
It is how a plan keeps provider agreements, amendments, fee schedules and payment policies in a form claims, dispute and network staff can use — and how it makes sure claims pay what was signed. Provider Contract Management answers any rate or clause question as a rate card for the date of service, cited to the contract page, and checks every paid claim against it each night.
The rate resolver takes the signed terms whose effective date is on or before the date of service, in effective order, and applies the latest one that governs the code. It uses the schedule amount for the year and locality the term names, applies payment policies, and shows the arithmetic and the governing page.
Yes. Each night the paid-claims checker compares every paid claim with its rate card, flags gaps above your tolerance, and looks back to the term’s effective date to find every claim with the same cause. The rate setup auditor then names the setup row behind it.
No. The agents never adjust, reprocess or recover a claim and never change rate setup. A provider dispute analyst signs responses and releases reprocessing; the rate configuration lead approves each setup change request.
They are read and filed, shown on the amendment ledger as drafts, and never applied to a rate. An amendment not yet in force on the date of service is shown as “Not yet in force”.
Each dispute arrives with its rate card and a drafted response that recommends uphold or deny, cites each provision, computes interest under the agreement, and names other claims with the same cause. The analyst edits if needed, signs and sends.
Your contract repository, Medicare fee schedules by year, locality and setting, your payment policies, the claims system’s rate setup export and the daily paid-claims file. Signed dispute responses go out through the provider portal.
The Agentic Solution Engine builds and deploys it from your requirements and documents — your agreements, fee schedules, payment policies and a sample of paid claims — and it goes live once every quality gate has passed. We will walk you through it on your own contracts first.
Every criterion shown met or not met, with the page that proves it.
1-min demoUtilization Management AutomationNo missed 72-hour or 7-day deadline, and the yearly metrics from the same data.
1-min demoAppeals & Grievances ManagementEvery appeal decided on time, with the full file read and what is new marked.
1-min demoWe’ll run Provider Contract Management on a sample of your own agreements and paid claims.