View the Expected Reimbursement Details

The Expected Reimbursement Detail page displays the expected reimbursement calculations for the applicable reimbursement and consists of the following sections:

• Patient Summary
• Master Account Summary
• Primary Payor Summary
• Reprice Summary
• Reimbursement Details

The Summary sections are the same, regardless of the claim type. Reimbursement Details section display varies, depending on the type of claim you are viewing. For example, Medicare, Medicaid, and TRICARE claims all differ in the reimbursement details that display.

The first portion of this procedure pertains to the summary sections. Following that, you must select a claim type to see more specific information.

Note: The Expected Reimbursement Detail page is not available for any account that is included in a PEM claim.

Procedure

1. Access the Expected Reimbursement Detail page.
   If you know the account number:

   1. Select Go To > Account Research > By Account Number. The Account Research by Account Number page opens.
   2. Type the account number and click Display Account. The Patient Account Audit page opens.
   3. Click a REIM link in the View column. The Expected Reimbursement Detail page opens.

      Note: The REIM link is disabled for any account that is included in a PEM claim.

   If you do not know the account number:

   1. Select Go To > Account Research > from Worklist. The Account Research from Worklist page opens.
   2. From the Task list, select Create Worklist.
   3. Specify other selection criteria and click Display Accounts. The Account Worklist page opens. For more information about search criteria, refer to Specify Account Worklist Criteria.

      Note: PEM claims are not included in worklist results.

   4. Click the account number you want to review in the Account Number column. The Patient Account Audit page opens.
   5. Click a REIM link in the View column. The Expected Reimbursement Detail page opens.

      Note: The REIM link is disabled for any account that is included in a PEM claim.

2. Review the expected reimbursement details.
   • Data for both standard and CCI (Correct Coding Initiative) edits is included.
   • On inpatient Medicare accounts, if there is a Remittance Advice (RA), the data is shown as a separate line item and the date of the RA appears with the results.
   • If the Remittance Advice feature is turned on for your facility and there is 835/RA data for an account, the RA data displays in a separate section. Lines with a difference between the expected and actual payments are highlighted.
   • If there is a denial (zero payment), the denial code is also displayed (up to 150 characters) in a separate table.
   • When the denial explanation is longer than the 150-character limit, click the link Click for full description to display the full explanation.
   • If there is a discrepancy between the UB and the RA, it might be because the FI changed the original DRG. There are other reasons for discrepancies, so follow your internal procedures or contact the FI to resolve discrepancies.

     Note: When viewing details for secondary and tertiary payors, the amounts shown in results grid at the bottom of the page reflect contractual values as though this payor were the primary payor. These values do not reflect the application of the Coordination of Benefits language. Refer to the Payor Summary section to see the expected payment based on the Coordination of Benefits language.”

   The reimbursement details vary by payer.

3. Optionally, you can perform the following actions:
   • Click a link in the Term Type column. The View Contract Profile page opens. For more information, refer to View a Contract Profile.
   • Click a link in the Service Type column. The View Contract Profile page opens. For more information, refer to View a Contract Profile.
   • Click the Bill Type link. The Billing Type Definition page opens. For more information, refer to Billing Type Definition.
   • Click an amount in a DRG Payment, Operating, or Capital column to get a step-by-step calculation for that amount.
   • Click the Write-Off Discount link (if present) to display the Account Write-Down Detail page. For more information, refer to View the Account Write-Down Detail.
   • Click the Total Expected Payment link. The Expected Payment Detail page opens. For more information, refer to View the Expected Payment Detail.
   • Click the Patient Liability link. The Patient Liability Override page opens. For more information, refer to Override Patient Liability.
   • Click Generate Resubmission Package. The Generate Resubmission Package page opens. For more information, refer to Letter Management.
   • Click Generate Patient Balance Package. The Generate Patient Balance Package page opens. For more information, refer to Letter Management.
   • Click Flag Account. The Assign/Update Collection Information page opens. For more information, refer to View the Account Worklist and Assign / Update Collection Information.
   • Click Recalculate as IPPS/OPPS. The Medicare Calculator opens. The Medicare Calculator page estimates the reimbursement based on the current account data or other “what if” selection criteria, which you can specify. The calculation has no effect on the actual account.
   • Click Recalculate as TRICARE. The TRICARE Calculator opens. The TRICARE Calculator page estimates the reimbursement based on the current account data or other “what if” selection criteria, which you can specify. The calculation has no effect on the actual account.
   • Click View in the Calculation Details column. The Calculation Details page opens. For more information, refer to View Expected Reimbursement Calculation Details.

Field Descriptions

For detailed descriptions of the summary sections, refer to the following:

• Patient Summary
• Master Account Summary
• Payor Summary
• Reprice Summary
• Reimbursement Details
• Grouper Information

Reimbursement Details

For detailed descriptions of the Reimbursement Details section, refer to the specific type of payer listed below.

Grouper Information

If the account was grouped by a version of the MS-DRG, APR-DRG, or TRICARE grouper, the Grouper Information section of the page includes the fields described below.

Field	Description
Claim DRG	The DRG originally submitted on the claim form.
Final DRG	The final DRG used to calculate expected reimbursement. This DRG may differ from the claim or original DRG if the Present on Admission (POA) indicator is used.
Grouper Version	The DRG grouper version used for this contract profile.
Message Code	Message code associated with this account.
Message Text	Description of the message code associated with this account.
Original DRG	The original grouped DRG before the Present on Admission (POA) indicators are applied. If the POA indicators are turned off, the Original DRG field is blank. If the POA did not result in a DRG change, the Original DRG and Final DRG fields display the same DRG value.
POA Used	Indicates whether the Present on Admission (POA) indicator is used for this contract profile. Note: This option is disabled for DRG grouper versions prior to 2008.