The Second Dollar Stop Loss reimbursement tool determines the second dollar stop loss threshold. This threshold amount can be based on either number of days or charges. Plan liability is only equal to reimbursement as of the threshold day or threshold charges, so the system calculates the claim based only on those days or charges below the threshold.
After calculating the reimbursement as of the threshold day or threshold charges, the Second Dollar Stop Loss tool resets the days/charges to the threshold value so that subsequent tools can perform calculations based on the days or charges above the threshold.
You must set a formula after the second dollar stop loss term to tell the system how to calculate the charges after the threshold. The standard formula is:
Billed Charges–(threshold amount X specified %) + Plan Liability Reimbursement + Cost Pass-Through Amount
Note: Once the second dollar tool activates, the Days In Visit operand becomes a variable. Days In Visit then becomes the days after the threshold, taking the totals days in the stay and subtracting the threshold days. Original Days In Visit is the total days in the stay, but it only becomes active when used in conjunction with the Second Dollar Stop Loss reimbursement tool.
Field DescriptionsThe following table describes the fields on the Second Dollar Stop Loss reimbursement tool.
Field | Description |
Calculate threshold day based on charge threshold | Option to calculate the threshold based on charges rather than days; the charge options are not available until you select this radio button |
Specify charge threshold | Uses the value entered as the charge threshold for second dollar stop loss |
Use charge threshold previously specified | Uses a charge-based threshold defined in a previous reimbursement term |
Use average daily charges instead of actual daily charges | Uses the day threshold based on average daily charges, instead of considering the actual charges for each day. |
Use threshold day | Option to calculate the threshold based on days rather than charges; the days options are not available until you select this radio button |
Specify threshold day | Uses the value entered as the number of days to use as the day threshold for second dollar stop loss |
Use threshold day previously specified | Uses a days-based threshold defined in a previous reimbursement term |
Include the day the threshold is exceeded | Includes all charges on the day the threshold is met when using the operand “calculated threshold amount”. |
Pay all pass-throughs regardless of the threshold date | Captures and calculates the reimbursement for pass-thru items without consideration to the occurrence date or threshold reimbursement |