View the Medicare Outpatient Expected Reimbursement Detail

Use the following procedure to view the Expected Reimbursement Detail for a Medicare outpatient.

Note: If the Expected Reimbursement Detail is incomplete, click a Service Type link.

The expected reimbursement for outpatient Medicare accounts is based on Ambulatory Payment Classification (APC) rules, so the information on the Expected Reimbursement Detail page for outpatient Medicare accounts is different from commercial outpatient accounts.

Field Descriptions – Medicare Outpatient

The following table describes each of the fields on the Expected Reimbursement Detail page for Medicare outpatients. The fields are listed by section.

Field	Description
Claim Error	Error code for the claim level
Claim Disposition	Disposition code for claim level
Reimbursement Type	Reimbursement type, either expected reimbursement or RA, if applicable (the latest RA is shown if there are multiple RAs)
Pre SR Total Payments / PPS Payment	The total payments expected amount from Medicare before the sequestration reduction is applied. This field is shown only if the Apply sequestration reduction option is selected on the reimbursement tool.
Sequestration Reduction (SR)	The 2% sequestration reduction for patients discharged on or after 04/01/2013. The reduction is applied to the expected payment for each line item after any applicable co-payment amounts are applied. This field is shown only if the Apply sequestration reduction option is selected on the reimbursement tool.
APC Payment, Excluding Outliers	Total reimbursement by the Ambulatory Payment Classification, a set of payment rates based on groups of outpatient services rather than on individual services
New Tech Pass-Through Payments	Total reimbursement for certain high-cost items, such as implants, high cost drugs, and biologicals, for which the actual or higher cost is passed through to the payor
Fee Schedule Payments / Composite Rate Payment	Total reimbursement from a fee schedule (Lab, DMEPOS, PEN and therapies)
Total Deductible - RA, Only	The total deductible imported or retrieved from the Remittance Advice.
Total Claim Outlier Payments	Total amount for extraordinarily high cost (cost outlier) for that service date
Post SR Total Payments / PPS Payment (Including Outliers)	The total payments expected amount from Medicare after the sequestration reduction is applied. This field is shown only if the Apply sequestration reduction option is selected on the reimbursement tool.
Total Medicare Payment	Total Medicare payment
Total Patient Responsibility	Patient co-payment, as stipulated by the rules
No.	Sequential reference number of the line item
Line Item Date of Service (LIDOS)	Dates the service was rendered
Revenue Code	Revenue code
CPT/HCPCS Codes & Modifiers	Associated CPT or HCPCS codes and modifiers
APC Codes	Ambulatory Payment Classification codes
APC Weight	The Ambulatory Payment Classification (APC) weight applied to the line item
Payment Status Indicators	APC payment status code. See the Payment Status Code Definitions section for descriptions.
Billed Units	Number of units billed
Charges	Total amount billed by the provider
Pre SR Expected Base Payment	The calculated reimbursement based on the predefined contract terms and conditions, the service type definitions in the system, and the repriced claims data before the sequestration reduction is applied. This field is shown only if the Apply sequestration reduction option is selected on the reimbursement tool.
Sequestration Reduction (SR)	The 2% sequestration reduction for patients discharged on or after 04/01/2013. The reduction is applied to the expected payment for each line item after any applicable co-payment amounts are applied. This field is shown only if the Apply sequestration reduction option is selected on the reimbursement tool.
Post SR Expected Base Payment	The calculated reimbursement based on the predefined contract terms and conditions, the service type definitions in the system, and the repriced claims data after the sequestration reduction is applied. This field is shown only if the Apply sequestration reduction option is selected on the reimbursement tool.
Expected Base Payment	The calculated reimbursement based on the predefined contract terms and conditions, the service type definitions in the system, and the repriced claims data before the sequestration reduction is applied. This field is shown only if the Apply sequestration reduction option is selected on the reimbursement tool.
Actual Base Payment (RA)	The actual base payment used for Remittance Advice purposes.
RA Payment Variance	The difference between Expected Base Payment and Actual Base Payment (RA) when RA data is present.
Outlier Amount APC, only	Total APC amount for extraordinarily high cost (cost outlier) for that service date
Patient Co-Pay	The co-payment amount.
IP Deductible Capped Amount	The inpatient deductible capped amount.
Total APC Payment	Payment by APC for the line item
Message & Error Codes	Reason for rejection or return, if applicable
Payment Status Code Definitions	Definitions of Payment Status Codes listed