THIS SECTION IS FOR HEALTHCARE PROVIDERS THAT ALREADY CONTRACT, OR ARE LOOKING TO CONTRACT, AND ACCEPT ASSIGNMENT OF BENEFITS FOR OUR SELF-FUNDED TPA PLAN PARTICIPANTS
New solo or group practice?
Please complete, sign and return:
- Provider Service Agreement per tax ID #
- W-9 form per tax id #
- credentialing app per provider
- attestation release agreement per app
- All attachments requested on the app
Contracted & adding physician(s)?
Please complete, sign, and return:
- W-9 form per app
- credentialing app per provider
- attestation release agreement per app
- All attachments requested on the app
Looking for 2011 Reimbursement Amounts?
DEPHI CARD® Physician Reimbursement Schedules1 are based on Medicare's current physician fee schedule. To determine the reimbursement for a specific CPT-4 Code, multiply the Medicare amount by the factor shown below for the corresponding code range.
| Code Range | Factor |
| 10000-29999 & 50000-69999 | 2 |
| 30000-49999 | 2.2 |
| 70000-79999 | 1.9 |
| 80000-89999 | 1.82 |
| 90000-96999 & 99201-99245 | 1.2 |
| 97000-97999 | 1.3 |
| 98000-99195 | 1.25 |
| 99251-99999 | 1.15 |
1Only self-funded or partially self-funded clients access the above reimbursement schedules. Full insurance participants do not access this reimbursement schedule.
Fully insured DEPHI CARD® clients, the Provider will be reimbursed by the carrier according to whichever network the participant has access, whether or not Provider is contracted to that network, plan deductibles, copays, and all other plan stipulations.
2Codes within the 80000-89999 range are multiplied by different percentages. The % for this code range is an average.