Standard Service Package (SSP)

Standard Service Packages (SSPs) represent bundled healthcare services with guaranteed Direct Contract rates. SSPs can be single services or complex multi-component bundles.

Overview

An SSP is the commercial unit of healthcare pricing in Turquoise. Instead of pricing individual CPT codes, Direct Contracts reference SSPs, which may encompass multiple procedures, facility fees, and professional services.

Direct Contract
└── Plan: SHARP-HMO-2024
    └── Facility: Sharp HealthCare
        └── SSP: GI-Double-Header (rate: $2,400)
            ├── Component: EGD (CPT 43235)
            ├── Component: Colonoscopy (CPT 45378)
            └── Component: Facility fee

Field Reference

Field	Type	Required	Description
code	string	✓	Unique SSP identifier (e.g., "SSP-GI-DH-001")
name	string	✓	Display name (e.g., "GI Double Header Bundle")
description	string	✗	Human-readable description
level	string	✓	Pricing level: EPISODE, ENCOUNTER, ITEM_SERVICE
base_weight	decimal	✗	Relative complexity weight (1.0 = baseline)
medicare_rate	decimal	✓	Base Medicare reimbursement amount
primary_cpt_code	string	✓	Primary CPT (used for lookup)
secondary_cpt_codes	array	✗	Additional CPTs included in bundle
components	array	✗	Sub-components of bundle
direct_contract_rate	decimal	✓	Negotiated Direct Contract rate
member_responsibility	decimal	✓	Member copay/deductible
effective_date	date	✓	Contract start date (YYYY-MM-DD)
term_date	date	✓	Contract end date (YYYY-MM-DD)

Level Definitions

Level	Scope	Example
EPISODE	Complete episode of care (pre/post-op, multiple visits)	Hip replacement + 6 weeks PT
ENCOUNTER	Single facility visit or day	Colonoscopy with facility + professional fees
ITEM_SERVICE	Individual service line	EGD only

Basic SSP Example

Single procedure SSP for EGD:

{
  "code": "SSP-EGD-001",
  "name": "Esophagogastroduodenoscopy (EGD)",
  "description": "Diagnostic or therapeutic endoscopy of upper GI tract",
  "level": "ITEM_SERVICE",
  "primary_cpt_code": "43235",
  "base_weight": 1.0,
  "medicare_rate": 800.00,
  "direct_contract_rate": 1200.00,
  "member_responsibility": 100.00,
  "effective_date": "2024-01-01",
  "term_date": "2024-12-31",
  "service_category": "gastroenterology"
}

Bundled SSP: GI Double Header

Complex bundle with multiple components:

{
  "code": "SSP-GI-DH-001",
  "name": "GI Double Header Bundle",
  "description": "EGD + Colonoscopy in single session",
  "level": "ENCOUNTER",
  "primary_cpt_code": "43235",
  "secondary_cpt_codes": ["45378"],
  "base_weight": 1.8,
  "medicare_rate": 1600.00,
  "direct_contract_rate": 2400.00,
  "member_responsibility": 150.00,
  "effective_date": "2024-01-01",
  "term_date": "2024-12-31",
  "components": [
    {
      "sequence": 1,
      "cpt_code": "43235",
      "description": "Esophagogastroduodenoscopy",
      "base_rate": 800.00,
      "direct_contract_rate": 1200.00,
      "facility_rate": 400.00,
      "professional_rate": 800.00
    },
    {
      "sequence": 2,
      "cpt_code": "45378",
      "description": "Colonoscopy",
      "base_rate": 800.00,
      "direct_contract_rate": 1200.00,
      "facility_rate": 400.00,
      "professional_rate": 800.00
    }
  ]
}

Component Structure

Each component represents a distinct service within the bundle:

{
  "sequence": 1,
  "cpt_code": "43235",
  "description": "EGD",
  "quantity": 1,
  "base_rate": 800.00,
  "direct_contract_rate": 1200.00,
  "facility_rate": 400.00,
  "professional_rate": 800.00,
  "modifiers": ["26"],
  "notes": "Professional component only (26 modifier)"
}

Field	Type	Description
sequence	integer	Order within bundle (1, 2, 3...)
cpt_code	string	CPT code for this component
description	string	Component description
quantity	integer	Number of units (default: 1)
base_rate	decimal	Base Medicare rate
direct_contract_rate	decimal	Negotiated rate for this component
facility_rate	decimal	Facility/institutional component (if split)
professional_rate	decimal	Professional component (if split)
modifiers	array	CPT modifiers (e.g., "26" = professional only)
notes	string	Special notes or conditions

Episode SSP: Hip Replacement with Post-Op

Multi-visit episode bundling surgery and recovery:

{
  "code": "SSP-HIP-REPL-001",
  "name": "Total Hip Replacement - Episode",
  "description": "Hip replacement surgery + 6 weeks post-operative care",
  "level": "EPISODE",
  "primary_cpt_code": "27130",
  "base_weight": 2.5,
  "medicare_rate": 15000.00,
  "direct_contract_rate": 18500.00,
  "member_responsibility": 500.00,
  "effective_date": "2024-01-01",
  "term_date": "2024-12-31",
  "episode_length_days": 42,
  "components": [
    {
      "sequence": 1,
      "cpt_code": "27130",
      "description": "Total hip replacement",
      "visit_type": "surgery",
      "direct_contract_rate": 15000.00,
      "facility_rate": 8000.00,
      "professional_rate": 7000.00
    },
    {
      "sequence": 2,
      "cpt_code": "97530",
      "description": "Physical therapy",
      "visit_type": "post-op_follow_up",
      "quantity": 12,
      "unit_rate": 150.00,
      "direct_contract_rate": 1800.00,
      "notes": "Up to 12 PT visits within 42 days"
    },
    {
      "sequence": 3,
      "cpt_code": "99213",
      "description": "Office visit - follow-up",
      "visit_type": "follow_up",
      "quantity": 2,
      "unit_rate": 100.00,
      "direct_contract_rate": 200.00,
      "notes": "2 follow-up visits included"
    }
  ]
}

SSP Lookup via Contract

When you perform a contract lookup with a CPT code, Turquoise returns the matching SSP:

curl -X POST \
  https://api.turquoise.health/tpa-api/v1/contracts/lookup \
  -H "X-API-Key: $TURQUOISE_API_KEY" \
  -d '{
    "provider_npi": "1234567890",
    "plan_id": "SHARP-HMO-2024",
    "service_code": "43235"
  }'

Response includes SSP details:

{
  "contract_id": "DIR-2024-001",
  "ssp_code": "SSP-EGD-001",
  "ssp_name": "Esophagogastroduodenoscopy",
  "negotiated_rate": 1200.00,
  "member_responsibility": 100.00,
  "plan_pays": 1100.00,
  "effective_date": "2024-01-01",
  "term_date": "2024-12-31"
}

SSP Pricing Rules

Rule 1: Bundle Discounts

Bundled SSPs (multi-component) offer discounts vs. individual services:

Individual EGD:         $1,200
Individual Colonoscopy: $1,500
Separate total:         $2,700

GI Double Header Bundle: $2,400 (13% savings)

Rule 2: Component Ordering

Components are paid in sequence. If claim only includes first component, it's priced as separate item, not bundle:

Claim with both CPT 43235 + 45378 → SSP-GI-DH-001 ($2,400)
Claim with only CPT 43235        → SSP-EGD-001 ($1,200)

Rule 3: Modifier Impact

Modifiers may change SSP assignment:

CPT 43235 (standard)    → SSP-EGD-001 ($1,200)
CPT 43235-26 (prof only) → SSP-EGD-PROF-001 ($600)
CPT 43235-TC (facility)  → SSP-EGD-FACILITY-001 ($600)

Rule 4: Episode Duration

Episode SSPs are valid for a specific time window:

{
  "ssp_code": "SSP-HIP-REPL-001",
  "episode_start": "2024-03-10",
  "episode_end": "2024-04-21",
  "episode_length_days": 42
}

Claims submitted after episode end date use standard rates.

SSP to Direct Contract Mapping

How SSPs connect to Direct Contracts:

Direct Contract
├─ Provider: Sharp HealthCare (NPI 1234567890)
├─ Plan: SHARP-HMO-2024
├─ Effective: 2024-01-01 to 2024-12-31
└─ SSP Mappings:
   ├─ SSP-EGD-001 → $1,200
   ├─ SSP-COLON-001 → $1,500
   ├─ SSP-GI-DH-001 → $2,400
   └─ SSP-HIP-REPL-001 → $18,500

Viewing Contract SSPs

List all SSPs for a specific Direct Contract:

curl -X GET \
  https://api.turquoise.health/tpa-api/v1/contracts/DIR-2024-001/ssps \
  -H "X-API-Key: $TURQUOISE_API_KEY"

Response:

{
  "contract_id": "DIR-2024-001",
  "ssps": [
    {
      "code": "SSP-EGD-001",
      "name": "Esophagogastroduodenoscopy",
      "direct_contract_rate": 1200.00
    },
    {
      "code": "SSP-COLON-001",
      "name": "Colonoscopy",
      "direct_contract_rate": 1500.00
    },
    {
      "code": "SSP-GI-DH-001",
      "name": "GI Double Header Bundle",
      "direct_contract_rate": 2400.00
    }
  ]
}

SSP-to-Claim Reconciliation

When you submit a claim, it's matched to an SSP. Verify the match in ClaimResponse:

# Submit claim
curl -X POST \
  https://api.turquoise.health/tpa-api/v1/claims/submit \
  -H "X-API-Key: $TURQUOISE_API_KEY" \
  -d '{
    "resourceType": "Claim",
    "id": "CLM-001",
    "item": [
      { "sequence": 1, "productOrService": { "coding": [{ "code": "43235" }] } },
      { "sequence": 2, "productOrService": { "coding": [{ "code": "45378" }] } }
    ]
  }'

# Response references SSP
{
  "resourceType": "ClaimResponse",
  "id": "CLMR-001",
  "extension": [
    {
      "url": "https://turquoise.health/ssp-code",
      "valueString": "SSP-GI-DH-001"
    }
  ],
  "adjudication": [
    {
      "category": { "coding": [{ "code": "allowedamount" }] },
      "amount": { "value": 2400.00 }
    }
  ]
}

Modifiers and SSP Adjustments

CPT modifiers can adjust SSP pricing:

Modifier 25 (Significant, Separately Identifiable Service)

Base SSP (with E/M): $1,500
Same day E/M (Modifier 25): +$150
Total: $1,650

Modifier 26 (Professional Component Only)

Full SSP: $1,200 (includes facility)
Professional only (Modifier 26): $600

Modifier 50 (Bilateral Procedure)

Unilateral: $1,200
Bilateral (Modifier 50): $2,000 (instead of $2,400)

Testing SSP Lookups in Sandbox

Test these CPT codes in sandbox:

CPT	SSP	Rate
43235	SSP-EGD-001	$1,200
45378	SSP-COLON-001	$1,500
43235 + 45378	SSP-GI-DH-001	$2,400

# Test single EGD
curl -X POST \
  https://sandbox.api.turquoise.health/tpa-api/v1/contracts/lookup \
  -H "X-API-Key: $TURQUOISE_API_KEY" \
  -d '{"service_code": "43235", "plan_id": "SHARP-HMO-2024", ...}'

# Test double header (submit both CPTs in claim)
curl -X POST \
  https://sandbox.api.turquoise.health/tpa-api/v1/claims/submit \
  -H "X-API-Key: $TURQUOISE_API_KEY" \
  -d '{
    "item": [
      {"productOrService": {"coding": [{"code": "43235"}]}},
      {"productOrService": {"coding": [{"code": "45378"}]}}
    ]
  }'

Best Practices

1. Use primary CPT for lookups: Always use the primary CPT when performing contract lookups
2. Submit all components: If claiming a bundle, include all component CPTs in the claim
3. Check modifier impact: Verify modifiers don't affect SSP assignment
4. Validate rates: Compare returned rates to latest contract documentation
5. Monitor bundle usage: Track if bundles are being matched correctly

Next Steps

• FHIR Claim Schema
• Settlement Record Schema
• Contract Lookups