If implants might be exclusion procedures and non-exclusion procedures are reimbursed at 70% after $100,000, what must you add to the contract line?

If implants might be exclusion procedures and non-exclusion procedures are reimbursed at 70% after $100,000, what must you add to the contract line?

• A. A Simple stop loss pricing extension with exclusions
• B. A Selection extension that identify the implant charges should not be included in the calculation of a stop-loss amount
• C. A Pricing extension with exclusions
• D. A Group extension with exclusions

Answer: (B)

Stop-loss calculations depend on which procedures are included in the calculation and which are excluded. When implants are treated as exclusions, their charges must not count toward the stop-loss amount. A Selection extension is the mechanism that lets you specifically identify certain charges—like implants—as excluded from the stop-loss computation. By tagging implant charges to be excluded, the stop-loss amount is calculated only on the non-excluded procedures, which matches the scenario where implants aren’t part of the stop-loss trigger. The other extensions—while they relate to pricing or grouping with exclusions—don’t provide the precise way to flag implant charges for exclusion from the stop-loss calculation itself.

Stop-loss calculations depend on which procedures are included in the calculation and which are excluded. When implants are treated as exclusions, their charges must not count toward the stop-loss amount.

A Selection extension is the mechanism that lets you specifically identify certain charges—like implants—as excluded from the stop-loss computation. By tagging implant charges to be excluded, the stop-loss amount is calculated only on the non-excluded procedures, which matches the scenario where implants aren’t part of the stop-loss trigger.

The other extensions—while they relate to pricing or grouping with exclusions—don’t provide the precise way to flag implant charges for exclusion from the stop-loss calculation itself.