Clinics - Ambulance - Home Health Tab

The Clinics - Ambulance - DMEPOS/PEN - NDC tab provides the ability to define reimbursement for Medicare services not included in OPPS and ASC. Typically, this tab is used to support managed care contracts based on Medicare.

The tools on this tab can be used in conjunction with the Ambulatory Payment Classification (APC) methodology on the Hosp tab, but cannot be used with either methodology on the ASC tab.

Note: Refer to the contract to determine the options to select and the values to enter.

The following process is recommended when defining Medicare OP reimbursement terms for managed care contracts:

Use the default settings unless the contract specifically indicates otherwise.
Price claims and look for patterns (such as E&M paying, with or without Mod-25), and then adjust the tool to eliminate those payment variances.

RHC

Use the RHC tool to define reimbursement terms related to rural health clinics.

Note: Refer to the contract to determine the options to select and the values to enter.

Field Descriptions

The following table describes the fields for the RHC reimbursement tool, available on the Clinics - Ambulance - Home Health tab of the Medicare OP reimbursement tool.

Field	Description
Apply sequestration reduction	Provides the option to apply the 2% Medicare sequestration reduction to that contract. This option does not affect the calculation of co-payment amounts.
Co-Pay for Preventive Services	Provides the ability to override the co-pay amount for preventive services by a percentage (up to three digits) of either the actual charges or the preventive services rate. The default value for this field is 20%.
Co-Pay for Visit	Provides the ability to override the co-pay amount for the visit by a percentage (up to three digits) of either the actual charges or the visit rate. The default value for this field is 20%.
Override Provider Number	Preferred provider number. Up to ten alphanumeric digits.
Override Service Date	Preferred service date. Use MM/DD/YYYY format. Temporarily sets the service date on the claim with the date you enter.
Percent of Visit Rate	Provides the ability to override the Medicare visit rate by a percentage amount (up to three digits). The default value for this field is 100%.
Rural Health Clinic (RHC) Pricing	Selecting this check box activates the RHC pricing logic

FQHC

Use the FQHC tool to define reimbursement terms for Federally Qualified Health Centers (FQHC).

After 10/01/2014 (FY2015), Federally Qualified Health Centers (FQHC) will be converted to a Prospective Payment System (PPS) pricing logic as each one ends its current Medicare year.

Prior to this change, claims were paid at a “per visit” rate with additional payment for certain nursing services, screenings, preventive services and so forth.
Claims from FQHC facilities that do not convert on 10/01/2014 will continue to be priced under the existing OPPS rules until they begin their next Medicare year.

Field Descriptions

The following table describes the fields for the FQHC tool, available on the Clinics - Ambulance - Home Health tab of the Medicare OP reimbursement tool.

Field	Description
Override Provider Number (CCN)	Required for all Contract Profiles except Medicare traditional fee for service.
Override Service Date	Required when the date on the claim does NOT drive pricing.
New Patient Rate	The managed care rate for new patients.
Established Patient Rate	The managed care rate for established patients
This is a Medicare Advantage Plan	Check this box to for Medicare Advantage plans. Note: If revenue code 0519 is on the claim, pricing is for the Medicare supplemental payment.
Apply co-pay to visit rates	Check this box if co-payments are required for per visit rates. Note: Some managed care plans will waive patient co-payments.
Apply co-pay to Preventive Services	Check this box if co-payments are required for per preventative services. Note: Medicare waives co-payments on preventative services, but many managed care plans do not.
Co-pay percentage	Enter the co-pay percentage if either of the co-pay options are checked: Apply co-pay to visit rates Apply co-pay to Preventive Services Note: The Medicare default co-pay is 20%.
Apply Sequestration Reduction	Check this box to apply the sequestration reduction. Note: Most non-government payers do not apply the sequestration reduction.
Sequestration Reduction Percentage	Enter the sequestration reduction percentage if the sequestration reduction is being applied. Note: The Medicare default is 2%.

Ambulance

Use the Ambulance tool to define reimbursement related to ambulance services.

Note: Refer to the contract to determine the options to select and the values to enter.

Field Descriptions

The following table describes the fields for the Ambulance reimbursement tool, available on the Clinics - Ambulance - Home Health tab of the Medicare OP reimbursement tool.

Field	Description
Air	Provides the option to reimburse air ambulance services as either a percentage of the fee schedule amount or as a percentage of the actual charges by selecting the appropriate option and typing a percentage in the text field.
Ambulance (Ground and Air) Pricing	Selecting this check box activates the Ambulance pricing logic
Apply sequestration reduction	Provides the option to apply the 2% Medicare sequestration reduction to that contract. Note: This option does not affect the calculation of co-payment amounts.
Co-Pay Percent	Provides the option to calculate the co-pay percentage as either a percentage of the fee schedule amount or as a percentage of the actual charges by selecting the appropriate option and typing a percentage in the text field.
Ground	Provides the option to reimburse ground ambulance services as either a percentage of the fee schedule amount or as a percentage of the actual charges by selecting the appropriate option and typing a percentage in the text field.
Override Provider Number	Preferred provider number. The value in this field is populated by the same field on the Hosp tab and cannot be edited on this tab.
Override Service Date	Preferred service date. Use MM/DD/YYYY format. Temporarily sets the service date on the claim with the date you enter.

Home Health

Use the Home Health tool to define reimbursement related to home health (Medicare profiles that do not apply PDGM).

Field Descriptions

The following table describes the fields for the Home Health reimbursement tool, available on the Clinics - Ambulance - Home Health tab of the Medicare OP reimbursement tool.

Field	Description
Home Health Pricing	Selecting this check box activates the Home Health pricing logic.
Override Provider Number	Preferred provider number. The value in this field is populated by the same field on the Hosp tab and cannot be edited on this tab.
Override Service Date	Preferred service date. Use MM/DD/YYYY format. Temporarily sets the service date on the claim with the date you enter.
Override Percentage	Provides the option to enter the profile override percentage when calculating reimbursements other than 100% on and after 01/01/2020. This text box defaults to 100%.
Apply Non-timely Submission Reduction	This option defaults to checked.
Apply sequestration reduction	Provides the option to apply the 2% Medicare sequestration reduction to that contract. Note: This option does not affect the calculation of co-payment amounts.
Hospice Pricing	Selecting this check box activates the Hospice pricing logic.
Override Provider Number	Preferred provider number. The value in this field is populated by the same field on the Hosp tab and cannot be edited on this tab.
Override Service Date	Preferred service date. Use MM/DD/YYYY format. Temporarily sets the service date on the claim with the date you enter.
Override Percentage	Provides the option to enter the profile override percentage when calculating reimbursements other than 100% on and after 01/01/2020. This text box defaults to 100%.
Apply Sequestration Reduction	Provides the option to apply the 2% Medicare sequestration reduction to that contract. Note: This option does not affect the calculation of co-payment amounts.