What are Direct Contracts?
Direct contracts are any instance of a Plan Designer's agreement with a specific Provider to provide care for their member's at a specific, often generous, contracted rate.
Yuzu’s Direct Contract hosting feature allows Plan Designers to host repricing information directly in Yuzu. But we need specific information in specific formats to get things your contracts and running.
General Needs for all Direct Contract Types:
The signed contract itself (& confirmation of preferred payment method)
List of services & contracted rates
List of their own providers (NPIs) & TINs
Yuzu divides direct contracts into three buckets. Ordered from lowest-touch (least information needed) to highest touch (most information needed) we have:
Subscriber-fee/Plan-claims agreements
Traditional "Direct Contracts" Preferred-Provider/Tier 0 agreements
Internal Networks/Provider-systems agreements
Subscriber-fee/Plan-claims agreements
How do we define a Subscription-Based/Plan-claim Provider Direct Contract?
These direct-contracts are set up like any other vendor on the plan, with the only difference being that they will provide care to the member.
What do we need to set this style of Direct Contract up?
Signed contract if available
Form of payment — Does this provider charge PEPM, PMPM, Plan Claims, some other way?
Will also need to have them added as a vendor in the portal, and get them to enter in Banking so that we can set up related fees or pay related invoices.
Cost to member — Should be $0 cost to member unless otherwise specified, our preference is $0 to member so that we do not need to build out additional accumulators.
Preferred Provider/Tier 0 Direct Contracts
How do we define Preferred-Provider/Tier 0 Direct Contracts?
This are our most "Traditional" definition of Direct Contracting, often paired with a generous $0 care tier where members can enjoy $0 Deds/MOOPs should they visit these preferred providers. Our PDs will provide us with a list of preferred providers (and relevant additional details) and we'll set them up as a Direct Contract within Plan Designs Networks. These providers can then submit claims directly to Yuzu and we will set them up in the system so that our claims engine reprices them to the PD-contracted rates. They are then adjudicated like any other claim.
What do we need to set this style of Direct Contract up?
Signed contract
List of services --> Procedure Codes (a.k.a. CPT codes) or Revenue Codes, ranges of codes preferred
Contracted rates --> Given as a Flat Rate ($), % of Billed Charges, or % of Medicare Rates
Provider details --> Only need Organization/Provider Name, NPI & TIN, and Start Date to process claims
Provider Mass Import File (DC).xlsx
Provider-Systems/Internal Network Direct Contracts
How do we define Provider-Systems/Internal Network Direct Contracts?
This is a Directly Contracted agreement with an nascent network of providers that wishes to use our system as their repricing engine. To the member they'll appear like a more generous local-network but on the back end they are built out much like we would build out the "Traditional" Direct Contracts. The main exception is that instead of the plan designer coordinating separate rates from multiple preferred providers and having us set up each in our system, they'll contract network-wide rates to cover all sorts of services from this single system of providers.
What do we need to set this style of Direct Contract up?
Signed contract
Rates (should work to get these as one-to-one as possible, all rates should map to specific codes and we should avoid catchalls like "all other services" as much as possible)
List of services --> Procedure Codes (a.k.a. CPT codes) or Revenue Codes, ranges of codes preferred
Contracted rates --> Given as a Flat Rate ($), % of Billed Charges, or % of Medicare Rates
Providers
Provider details --> Only need Organization/Provider Name, NPI & TIN, and Start Date to process claims, to utilize "Find Care" features as a network we'll need this full file completed. Push for as much detail as possible in the initial upload.
Provider Mass Import File (Network).xlsx
When Can Yuzu Not Support Direct Contracts?
Claims-creating direct contracts cannot be supported when we are not the primary Payor ID on the plan, or if Payor listed will not allow richer-benefits than their INN tier (for example, in a Cigna plan)
Claims-creating direct contracts are also limited in HDHP plans, as sold benefits like "$0 care" or "100% covered by plan" cannot kick in until member hits their deductible.
Direct Contracts set up after plan go-live cannot be retroactively applied to existing claims. Contracts set up after go live will have an effective date of their entry into the system and only net new claims will be repriced per those terms.