View Expected Reimbursement Calculation Details
The Expected Reimbursement Calculation Details page displays the detailed calculations used to generate reimbursement values. Detailed calculations are only available for the following reimbursement tools; other tools display only the higher level calculations on this page.
- If Test
- Group
- Interim
- Percentage
- Per Diem
- Flat
- DRG Lookup
- FormulaCPE
Calculation details are displayed using nesting to represent the progress of the calculations performed. A calculation is nested inside another calculation (a box within a box) for any of the following reasons:
- When one term is the child of another, such as a formula that is executed when an If Test is found to be True or False.
- When a term uses complex calculations, such as a formula with multiple operands, one or more levels of nesting might be used to show the relationships of the individual calculations.
Note: The calculations on this page are real-time calculations and default to the most recent version of the claim profile. If this profile or any related tables have changed since the claim was originally repriced, the total reimbursement shown on this page might differ from the total reimbursement shown on the Expected Reimbursement Details page.
Use the following procedure to view the calculation details for a specific service type on an account.
Procedure
- Access the Calculation Details page.
- Access the Expected Reimbursement Detail page. For more information, refer to View the Expected Reimbursement Details .
- Click View in the Calculation Details column. The Calculation Details page opens.
- Review the calculations.
- The Contract Profile Summary section shows the contract profile used for the calculations on this page. This might differ from the profile used for the original reprice.
- The Calculation section shows each step of the calculation. Relationships between calculations are displayed through nested boxes, so that a calculation that is a subset of a larger calculation is shown as a smaller box within the larger calculation. For complex calculations, several levels of nesting might display.
- Optionally, you can perform the following actions:
- Change the way the calculations display by selecting one or more of the following check boxes and clicking Refresh Display:
- Hide Subtotals – Hides all subtotals in the Calculation Details section. Subtotals displays when a calculation has more than two steps and shows the subtotal for each step of the calculation.
- Hide Display Boxes – Hides the borders of the boxes that hold calculation groups. The formatting of the calculations remains the same.
- Hide Shading – Hides the shading of the boxes that hold calculation groups. The formatting of the calculations remains the same.
- Click the Contract Name link. The View Contract Profile page opens. For more information, refer to Manage Contract Profiles.
- Click the Bill Type link. The Billing Type Definition page opens. For more information, refer to Billing Type Definition.
- Change the way the calculations display by selecting one or more of the following check boxes and clicking Refresh Display:
Field DescriptionsThe following table describes the fields on the Calculation Details page.
Field | Description |
Account Number | Patient account number (for UB claims) or insured ID (for CMS-1500 claims) |
Activation Date | The date the contract is available for processing. If a contract profile was changed, you might see multiple activation dates |
Active Status | Indicates the purpose and progress of the contract profile |
Admit Date | Date of admission for the account |
Anchor Date | Artificial date of service for all claims associated with the scenario |
Bill Type | Bill type |
Contract | Contract Profile Name |
Dates of Service | The range of date of service from and date of service to for the claim |
Effective Date | Effective date of the current contract rates |
Hide Display Boxes | Hides the borders of the boxes that hold calculation groups. The formatting of the calculations remains the same. |
Hide Shading | Hides the shading of the boxes that hold calculation groups. The formatting of the calculations remains the same. |
Hide Subtotals | Hides all subtotals in the Calculation Details section. Subtotals displays when a calculation has more than two steps. |
Medicare Outlier Date | The date on which Medicare Inpatient claims reach the outlier threshold, based on detail charges. |
Patient Name | Patient name |
Patient Payment | Portion paid by the patient |
Patient Type | Patient type assigned to the account: Inpatient/Outpatient |
Primary Diagnosis | Primary diagnosis code. This field provides a link to additional information about the code.
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Product | Name of the insurance product selected |
Reimbursement Terms | The formula that calculates how much is paid for a service and any limitations on payment |
Termination Date | The termination date of the contract, if any is present and the customer requested it to be included |
Links on the Calculation Details Page- Account Audit displays the Patient Account Audit page. For more information, refer to View the Patient Account Audit Page .