View the Pennsylvania Workers’ Compensation (Inpatient) Expected Reimbursement Detail

Use the following procedure to view the Pennsylvania Workers’ Compensation (Inpatient) Expected Reimbursement Detail.

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

  • The RCC table allows customers to price revenue codes to a percent of billed charges when the reimbursement is pricing to 0.00.
  • The customer provides the Revenue Codes, and a Percentage, which calculate at percent of Billed Charges.
  • The Payment Indicator is D for these line items.
  • The Clinical lab listed on the Part B table takes precedent over the Service Codes listed in the Cost Allowance Files (CAF).
  • The payment indicator is B on these claims.
  • These are customer provided.
  • The customer needs to send files with a Salesforce case.
  • Pennsylvania Workers Comp publishes the CAF files quarterly.
  • These are facility specific.
  • Customer must state the total numeric characters desired for the Service Codes. See the following examples:
    • Service Code 4561 must be billed as 4561, if loaded with only four characters.
    • If Service Code 4561 is to be billed as 00004561, the request needs to be for eight characters.
  • The payment indicator is A on these claims.
  • Items with revenue codes beginning with 025 or 063, the line-item charges are multiplied by the ratio of the costs-to-charges (RCC) and then multiplied by 1.13.
  • The unique Medicare Provider Number bases the RCC.
  • The RCC amount is found in the Provider table.
  • The payment indicator is C for these claims.
  1. Access the Expected Reimbursement Detail page for a Pennsylvania Worker’s Compensation Inpatient account. For more information, refer to View the Expected Reimbursement Details .
  2. Review the expected reimbursements.
  3. Optionally, you can perform the following actions:

The following table describes each of the fields on the Expected Reimbursement Detail page for Pennsylvania Workers’ Compensation inpatient claims. The fields are listed in alphabetical order.

Field

Description

Avg. LOS

The average length of stay (in days) for that DRG code.

Capital Payment

Total capital adjustment

Disproportionate Share Add-on

Additional payment required by federal law that is made to qualifying hospitals that serve a large number of Medicaid or uninsured individuals

DRG

Diagnosis Related Group. If the DRG was submitted with a Severity of Illness code, it displays as DOG-Severity Code, for example, 001-2.

DRG Payment

Payment consisting of the DRG weight multiplied by the conversion factor. Includes pass-through amounts

DRG Weight

DRG weight factor established by Medicare for each DRG

Expected Payment

The calculated reimbursement based on the predefined contract terms and conditions and service type definitions in the system and the repriced claims data

Hold Harmless Capital Rate

A hospital paid under the hold-harmless payment methodology receives a payment per discharge based on the higher of:

85% of reasonable costs for old capital costs (100% for sole community hospitals) plus an amount for new capital costs based on a proportion of the Federal rate. The proportion is equal to the ratio of the hospital's Medicare inpatient costs for new capital to total Medicare inpatient capital costs.

100% of the Federal rate.

LOS

Length of Stay, in days

Outlier Payment

Payment for extraordinarily high cost (cost outlier)

Payment Adjustment

Adjustment to the payment for indirect medical, direct medical, and paramedical add on payments