Download het supplement - KCE

KCE Reports 80S Maximum Billing Supplement 149
Figure AX.2 Matching algorithm IMA data to reimbursement codes
For a number of IMA records, no match was found due to the nature of the
nomenclature code (for some types of nomenclature codes, no fixed reimbursement
amount is used: pseudocode, lump sum,…). For IMA records referring to co-payments
(e.g. co-payment for hospital stays), the conversion between preferential status/no
preferential status was done code by code.
For most matched IMA records, multiple reimbursement codes with a similar
reimbursement amount were returned. For each of these IMA record-reimbursement
code pairs, the corresponding fee code was selected. Again, due to the nature of certain
nomenclature codes, no fee code could be selected.
For those with fee codes, the fee code with the smallest difference between actual copayment
and recalculated co-payment (fee-reimbursement) was selected.
This procedure resulted in one reimbursement code and one reimbursement fee with
their corresponding amounts for each matched IMA record.
Since pharmaceutical products are not included in the RIZIV/INAMI nomenclature
database, a post hoc adaptation of the co-payments by reimbursement category was
necessary, according to the algorithm in Table AX.2. No distinction was made between
small and large packages.