Hosp Tab

Preferred provider number. Up to ten alphanumeric digits.

Preferred service date. Use MM/DD/YYYY format. Temporarily sets the service date on the claim with the date you enter.

Provides an option to calculate a percentage (other than 100%) of the Medicare Total Payment so that Managed Medicare claims are pricing based on their contract language.

• When this box is selected, the individual component percentages are defined at the percentage entered and cannot be modified.
• When this box is clear, define the override percentages of Medicare that the contract pays for each of the following components separately (allowable range is 0 to 500):
  • Pass-Through Amount
  • APC Amount
  • Outlier Amount

When this box is clear, you can also define the override percentages for Fee Schedules either as a percentage of the fee schedule amount or as a percentage of the actual charges.

When selected, the Pass-Through Amount percentage is applied to the charges for lines with Status Indicator G and the APC Amount percentage is applied to charges for lines with all other Status Indicators.

Note: If the check box is not selected, the reimbursement follows traditional Medicare processing.

A check box in the Override Total Payment section. Enable this check box to calculate the co-payment using the APC percentage amount.

A check box in the Override Total Payment section. Enable this check box so that the APC percentage amount is used to determine the outlier eligibility.

A check box in the Override Total Payment section. Enable this check box to cap the APC payment at billed charges.

Select the fee schedule options:

• Reimburse the following 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:
  • Labs
  • Therapies/Mammography (billtype 85x)
  • DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies)

Typing a percentage for Therapies/Mammography indicates that the contract pays PT, OT, ST, and/or screening mammography by fee schedule or at a percentage of charges. If it pays only one of these service types, the TAC must specify revenue codes or CPTs to exclude the other therapies.

These Fee Schedule overrides cannot be defined individually if Override Total Payment is selected.

• Calculate co-payment on DME based on Charges
  • When this box is checked the co-payment for DME services is based on the actual charges, and the expected reimbursement is based on the lesser of the actual charges or the Fee Schedule amount.
  • When this box is cleared, the co-payment for DME services is priced on the actual payment rather than charges.
• Do not cap payments at billed charges - this option is not selected as the default. When this option is checked, it does not cap the SI A payments at billed charges.

Percentage of the total claim that is paid when nothing on the claim is payable under APCs or a fee schedule. If at least one service type is reimbursed, this option is bypassed.

Note: This option applies when the account prices to $0.00 and the APC grouper returns an error.

Number of years back the system must reference APC weights in order to calculate reimbursement accurately.

For example, if a contract is set up in 2005 and uses the weights from 2002, the system must reference the weights from three years ago (Years Retro is 3).

Allows you to specify the name of a fee table to use in place of the APC fee table. This allows you to price claims that pay based on the APC logic, but that do not use the APC payment rate. Type the name of the fee table you want to use in the text field.

Preferred APC Grouper version, identified by date. Use MM/DD/YYYY format or select a date from the calendar.

Preferred Pricer version, identified by date. Use MM/DD/YYYY format or select a date from the calendar to identify which national rates to use.

Preferred APC table. All available tables are listed in the drop-down list.

Preferred HCPCS fee schedule. All available fee schedule tables are listed in the drop-down list.

Provides the option not to consume units. This is used for contract carve outs.

Provides the option not to consume charges. This is used for contract carve outs.

When selected, indicates that the technical component reduction is applied to CPT codes with modifier CT:

• 5% reduction in 2016
• 15% reduction in 2017 and subsequent years

When selected, this option reduces payments for line items with modifier FX (X-rays taken with film) by 20% prior to applying the co-payment and Sequestration Reduction. This option is selected by default.

Note: Non-Medicare payers must clear this check box to prevent the 20% reduction from being applied.

When selected, indicates that a claim billed with modifier 22 on a line reimburses at 120% of the expected reimbursement

When selected, indicates that a claim billed with modifier 52 on a line reimburses at 50% of the expected reimbursement

When selected, indicates that a claim billed with modifier 53 on a line reimburses at 30% of the expected reimbursement

When selected, indicates that a claim billed with modifier 54 on a line reimburses as follows:

• 70% of the expected reimbursement if the HCPCS code has global days of 090
• 80% of the expected reimbursement if the global days on the HCPCS code is 010

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.

Three radio buttons that provide options to handle the processing of IP-Only Procedures (Status Indicator C line-items).

• Medicare - when selected (enabled), prices the entire claim to $0.00 with line-item definition code 018 for Status Indicator C, and line-item definition code 049 for the remaining line-item charges. This is the default selection.

  Note: This radio button defaults to selected (enabled).

• Managed Medicare - when selected (enabled), prices Status Indicator C to $0.00 with line-item definition code 018, and the rest of the claim prices per OPPS standard logic.

  Note: Note: This radio button defaults to unselected (disabled).

• Price at Billed Charges - when selected (enabled), prices Status Indicator C to 100% of billed charges with line-item definition code 018 and new line-item definition code 2126 for IP-only procedures paid at 100% of billed charges, and the rest of the claim prices per OPPS standard logic.

  Note: This radio button defaults to unselected (disabled).

Allows you to specify the wage index to override.

Allows you to enter the Operating CTC (Cost to Charge) value to override.

Allows you to enter the Part B Ration value to override.

Allows you to enter the Device CTC (Cost to Charge) amount to override.

Enter the 5-digit zip code for this override.

Select to apply Hold Harmless (TOPS).

Note: Activates the Apply TOPS Amount Only check box.

This option applies Medicare Critical Access Hospital (CAH) outpatient professional modifiers (AK, GF, SB, AH, and AE) with their respective reductions using the MPFS amounts for revenue codes 096X, 097X, or 098X in a CAH that has elected the optional method. Payment is based on the lesser of the actual charge of the facility specific MPFS amount less deductible and coinsurance times 1.15.

To apply the following modifiers, select the Apply MHFS PHYS/NON-PHYS Modifiers to CAH check box.

• AK - Service rendered in a CAH by a non-participating physician: [(facility-specific MPFS amount) times the non-participating physician reduction (0.95) minus (deductible and coinsurance)] times 1.15
• GF - Services rendered by a nurse practitioner (NP), clinical nurse specialist (CNS), or physician assistant (PA): [(facility-specific MPFS amount) times the non-physician practitioner services reduction (0.85) minus (deductible and coinsurance)] times 1.15
• SB - Services rendered in a CAH by a certified nurse-midwife: (0.65) [(facility-specific MPFS amount) minus (deductible and coinsurance)] times 1.15
• AH - Services rendered in a CAH by a clinical psychologist: Payment for the services of a clinical psychologist is based on the lesser of the actual charge or 100 percent of the MPFS: [(facility-specific MPFS amount) minus (deductible and coinsurance)] times 1.15.
• AE - Services rendered in a CAH by a nutrition professional/registered dietitian: [(facility-specific MPFS amount) times the registered dietitian reduction (0.85) minus (deductible and coinsurance)] times 1.15.

When selected, calculates multiple “T” status indicators with modifier 50 as follows:

• First SI = T with Modifier 50 at 150%
• Subsequent SI = T with Modifier 50 at 75%

When selected, the system overrides edit 040 and prices the line item. Edit 040 indicates that the line item is not payable because it is part of another line item on the same claim.

When selected, indicates that the contract pays all charges, regardless of whether there is both a procedure and physician visit.

When selected, the system overrides edit 039 and prices the line item. Edit 039 indicates that the line item is not payable because it is mutually exclusive to another line item on the claim.

Ignores the device code edit so it is not applied to claims repriced by this reimbursement tool. The device code edit requires the identification, by HCPCS, of the implant device in most implant cases. This check box defaults to unselected, indicating the edit is active, but most managed care plans do not require this edit.

When selected, the system ignores the Off Campus Pricing logic.

This is option is typically selected for Managed Medicare payers who do not want to use the Off Campus Pricing logic.

When not selected, indicates that observation charges are not repriced unless there is a diagnosis code for asthma, chest pain or MI on the claim. When selected, indicates observation is priced regardless of diagnosis.

Default is unchecked( not selected). When checked (selected), contracts apply an outlier to SI K APC codes.

Note: If your contract applies an outlier to SI K APC codes, please open a case via the portal for the Contract Support team to check (select) this check box for any applicable Medicare based contracts.

When selected, indicates the co-payment amounts for each line and for the claim totals are not calculated.

Note: If this option is selected, the Do not include co-payment amount in the Total Expected Payment option is disabled.

When selected, indicates the co-payment amounts are not included in the total expected payment.

When selected, this option prevents the Multiple Procedure Payment Reduction (MPPR) logic from being applied to "always therapy" discounting.

Provides the option to truncate the total. For example if a total is 100.85, it is truncated to 100. If left unchecked, the total will round to 101.

When selected, indicates that certain lab procedures are grouped by the FI when two or more appear on the same claim.