View the Illinois Medicaid OP (EAPG) Expected Reimbursement Detail

Use the following procedure to view the Illinois Medicaid Expected Reimbursement Detail for outpatient accounts using EAPG.

Field Descriptions – Illinois Medicaid OP Accounts (EAPG)

The following table describes the fields on the Expected Reimbursement Detail page for Illinois Medicaid OP claims using EAPG.

Field	Description
Error Code	The reason for rejecting or returning the claim, if applicable.
Error Code Description	Description of the error code at the claim level.
Action or Error Code	A code that denotes the payment action or exclusion at the claim line level, which explains the method of payment calculation.
Action or Error Code Description	Description of the action or error code at the line item level.
Allowed Units	Number of units allowed by reimbursement logic.
APG Adjusted Weight	Factor adjusted by blended and transition logic and then assigned to an APG that is used to calculate the specific payment for that APG.
APG Description	Medical APGs pay based on patient’s condition and service intensity (diagnosis and procedure) and utilize comprehensive packaging and bundling.
APG Weight	Factor assigned to each APG that is used to calculate the specific payment for that APG. Ratio of the relative complexity of the APG to the average complexity of all APGs.
Base Rate	Factor assigned by state for individual hospitals to be used in the total expected calculation.
Billed Units	Number of units billed.
Blended Payment	Factor adjusted by blended and transition logic and then assigned to an APG that is used to calculate the specific payment for that APG.
Blended Payment Percent	The percentage of the total payment based on the old reimbursement methodology (for example, 75% at initial implementation, 50% in 2010, and so on) applied to the facility-specific average payment throughout the period of the transition to full payment based on APGs.
Billed Charges	Amount of charges covered by Medicaid.
Edit Code	The code for Procedure, Revenue Code, or Relationship edits for not processing claim line.
Edit Code Description	Description of the code for Procedure, Revenue Code, or Relationship edits for not processing claim line.
Effective Date	Effective Date.
Final APG	APG which all services have been rolled under for processing reimbursement and doing final calculation.
Final APG Type	Code which denotes the packaging, bundling, and categorizing for multiple interrelated services into a single type group.
Final EAPG Type	Displays the final EAPG type (e.g., Ancillary, Drug, Medical Visit, etc.) assigned to each line item by the grouper.
Grouper Type	The actual grouper type used for this outpatient calculation.
Grouper Version	The current version used in this outpatient calculation.
HCPC/CPT Code & Modifier	Associated CPT or HCPC codes and modifiers.
NPI	Facility’s ten-digit National Provider Identification (NPI) number required on all claims
Payment Percent	Displays the percentage used in the calculation of the detail line total and is base on the Pricing Status.
Pricing Status	Payment action or exclusion at the claim line level, which explains the method of payment calculation. Displays the pricing status code and description.
Provider Number	Provider Number.
Psych Base Rate	Factor assigned by state for individual hospitals to be used in the psych total expected calculation.
Rehab Base Rate	Factor assigned by state for individual hospitals to be used in the rehab total expected calculation.
Reimbursement Type	Reimbursement type, either expected reimbursement or RA, if applicable (the latest RA is shown if there are multiple RAs)
Revenue Code	Revenue code.
Service Date	Date the service was rendered.
SMART Act	The SMART Act percentage used in the reimbursement calculation. If a facility does not meet the criteria for designation as a Safety Net or Critical Access hospital then it is subject to the reduction in reimbursement. This percentage is displayed and used in the total reimbursement calculation. Note: This field is displayed only when the value is less than 100% and the Total Expected Reimbursement value is less than the Total Blended Payment.
SMART Act Reduction	If Value set to Yes, then the actual calculated 96.5% less of 100% amount is shown on next line which is subtracted from 100% leaving total expected reimbursement for hospital types which fall under the SMART Act reduction restriction. If hospital type is Critical Access, then 100% of reimbursement is shown and the SMART Act reduction shows 0 amount.
State ID	The two-letter state identifier.
Total Blended Payment	The percentage amount of the total payment based on the new reimbursement APG methodology. This amount is then applied to the facility-specific average payment throughout the period of the transition to full payment based on APGs.
Total Expected Reimbursement	The calculated reimbursement based on the predefined contract terms and conditions and service type definitions in the system and the repriced claims data. Note: This value is also affected by the SMART Act percentage.
Total Non-Transition Payment	The percentage amount of the total payment based on the old reimbursement methodology. This amount is then applied to the facility-specific average payment throughout the period of the transition to full payment based on APGs.
Total Payment	The total insurance and patient payments posted to the account, as defined in the data.
Total Visit APG Payment	The percentage amount of the total payment based on the grouping of APG Types. This amount is then applied to the facility-specific average payment throughout the period of the transition to full payment based on APGs.