Difference between negotiated, derived and fee schedule negotiated type - related question

[gjclaxton]

This appears not to have been answered. There appear to be cases where all of the rates reported by payers for certain codes or code types are fee schedule rates. An example is Cigna, where all of the rates it reports for a number of MS-DRGs hospital NPIs in a city are reported as fee schedule rates. As I understand the rule and the schema, they should also be reporting a negotiated rate or a derived rate for these billing codes unless they do not create a derived rate in their normal course of business. That would be hard to imagine but it seems the only way this works with the schema. Cigna does report some custom rates for certain NPIs in the city, including some hospital NPIs, but each have a notation in the additional information field of either "Inpatient services not otherwise priced" or "Outpatient services not otherwise priced". There are several hospital NPIs where the custom rates only apply to outpatient services not otherwise priced, which which would not seem to provide a negotiated rate for the inpatient admissions represented by the MS-DRGs.
Is there some explanation for payers only providing fee schedule rates for these codes I might be missing? Thanks

Discussed in #716

^{Originally posted by hung-payerprice October 10, 2023}
I'm confused about the difference between the 3 negotiated types negotiated, derived and fee schedule If I understand correctly, the units of all 3 rates are dollar, not percentage.

Can someone please explain to me how they are different? An example would be great e.g if there are 3 different rates, one for each type, when to use each of them? Thanks!

The previous discussion here didn't seem to reach a conclusion.

The official doc said the following but i don't really understand what they mean

negotiated: If applicable, the negotiated rate, reflected as a dollar amount, for each covered item or service under the plan or coverage that the plan or issuer has contractually agreed to pay an in-network provider, except for prescription drugs that are subject to a fee-for-service reimbursement arrangement, which must be reported in the prescription drug machine-readable file. If the negotiated rate is subject to change based upon participant, beneficiary, or enrollee-specific characteristics, these dollar amounts should be reflected as the base negotiated rate applicable to the item or service prior to adjustments for participant, beneficiary, or enrollee-specific characteristics.

derived: If applicable, the price that a plan or issuer assigns to an item or service for the purpose of internal accounting, reconciliation with providers or submitting data in accordance with the requirements of 45 CFR 153.710(c).

fee schedule: If applicable, the rate for a covered item or service from a particular in-network provider, or providers that a group health plan or health insurance issuer uses to determine a participant’s, beneficiary’s, or enrollee’s cost-sharing liability for the item or service, when that rate is different from the negotiated rate.