View the California Medicaid IP Expected Reimbursement Detail (APR-DRG)
Use the following procedure to view the California Medicaid Expected Reimbursement Detail for inpatient accounts using APR-DRG.
Note: If the Expected Reimbursement Detail is incomplete, click a Service Type link.
Procedure
- Access the Expected Reimbursement Detail page for a California Medicaid inpatient accounts using APR-DRG. For more information, refer to View the Expected Reimbursement Details .
- Review the expected reimbursements.
- Optionally, you can perform the following actions:
- Click View in the Calculation Details to display the Calculation Details page. For more information, refer to View Expected Reimbursement Calculation Details.
- Click Re-calculate as Medicare IPPS to display the Medicare Outpatient Calculator. For more information, refer to Use the Medicare Outpatient Calculator.
- Click Re-calculate as TRICARE IPPS to display the TRICARE Outpatient Calculator. For more information, refer to Use the TRICARE Non-OPPS Calculator.
Field Descriptions – California Medicaid IP APR-DRG
The following table describes the fields on the Expected Reimbursement Detail page for California Medicaid inpatient accounts using APR-DRG. The fields are listed in alphabetical order.
|
Field |
Description |
|
Cost Outlier Payment |
A cost outlier occurs if a hospital's charges exceed a specified amount above the statewide average price. |
|
Covered Charges |
The amount of covered charges |
|
Covered Days |
Number of covered days |
|
CTC Ratio |
Facility-specific charge-to-cost ratio |
|
DRG |
Diagnosis Related Group code. If the DRG was submitted with a Severity of Illness code, it displays as DRG-Severity Code, for example, 001-2. |
|
DRG Base Rate |
The base rate for the specified DRG |
|
DRG Payment |
Payment consisting of the DRG weight multiplied by the conversion factor. Includes pass-through amounts |
|
DRG Weight |
DRG weight factor established by Medicare for each DRG |
|
Effective Date |
Effective date of the current contract rates |
|
Error Code |
Reason for rejection or return, if applicable |
|
Non-covered Charges |
The amount of non-covered charges (not disallowed charges) |
|
NPI |
The ten-digit National Provider Identification (NPI) number required on all claims. |
|
Reimbursement Type |
Reimbursement type, either expected reimbursement or RA, if applicable (the latest RA is shown if there are multiple RAs) |
|
State ID |
Two-letter state identifier used by Medicare (e.g., CA) |
|
Total Expected Reimbursement |
The calculated reimbursement based on the predefined contract terms and conditions and service type definitions in the system and the repriced claims data |
|
Transfer Payment |
Payment amount if UB has a transfer discharge status; in place of DRG Inlier payment |