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

• 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.

• None of the Pennsylvania Workers’ Compensation Facility Factors display on the Contract Manager Provider Profile.

1. Access the Expected Reimbursement Detail page for a Pennsylvania Worker’s Compensation Outpatient account. For more information, refer to View the Expected Reimbursement Details .
2. Review the expected reimbursements.
3. 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 All OP 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 Pennsylvania Workers’ Compensation outpatient claims. The fields are listed in alphabetical order.