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.

- Access the Expected Reimbursement Detail page for a Medicare Outpatient account. For more information, refer to View the Expected Reimbursement Details .
- Review the expected reimbursements.
- Optionally, you can perform the following actions:
- Click Reimbursement to display the View Contract Profile page. For more information, refer to View a Contract Profile.
- Click Medicare OPPS to display the service types on the View Contract Profile page. For more information, refer to View a Contract Profile.
- Click View in the Calculation Details column. The Calculation Details page opens. For more information, refer to View Expected Reimbursement Calculation Details.

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 |
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 |