View the Texas Medicaid ASC Expected Reimbursement Detail

Use the following procedure to view the Texas Medicaid ASC Expected Reimbursement Detail.

Note: If the Expected Reimbursement Detail is incomplete, click a Service Type link.

  1. Access the Expected Reimbursement Detail page for a Texas Medicaid ASC account. For more information, refer to View the Expected Reimbursement Details . 
  2. Review the expected reimbursements.
  3. Optionally, you can perform the following actions:
    • Click Reimbursement to display the View Contract Profile page. For more information, refer to View a Contract Profile.
    • Click the Service Type name to display the service types on the View Contract Profile page. For more information, refer to View a Contract Profile.
    • Click View in the Calculation Details column. The Calculation Details page opens. For more information, refer to View Expected Reimbursement Calculation Details.
    • Click the Total Reimbursement amount to enter an account override. This link is only available for ASC CPT codes that do not have a specific fee schedule and are “paid by report.” For more information about entering an account override, refer to Add Account Override Data.
    • Click Re-calculate as Medicare OPPS to display the Medicare Outpatient Calculator. For more information, refer to Use the Medicare Outpatient Calculator.
    • Click Re-calculate as TRICARE Non-OPPS to display the TRICARE Non-OPPS Calculator. For more information, refer to Use the TRICARE Non-OPPS Calculator.

The following table describes the fields on the Expected Reimbursement Detail page for Texas Medicaid ASC claims.

Field

Description

ASC Group Number

Ambulatory Service Center group number assigned to the procedure by Medicare.

ASC High Volume Reimbursement

Displays the Ambulatory Service Center High Volume reimbursement amount calculated using the High Volume Percentage.

ASC Reimbursement

Displays the Ambulatory Service Center reimbursement amount from the Fee Schedule.

Billed Charges

The total charges incurred for the claim or set of claims that have been repriced.

CHIRP Add-On

Displays the Comprehensive Hospital Increase Program (CHIRP) add-on amount.

CHIRP Rate

Displays the Comprehensive Hospital Increase Program (CHIRP) rate.

CHIRP Reimbursement

Displays the Comprehensive Hospital Increase Program (CHIRP) reimbursement amount.

CPT / HCPC Codes & Modifiers

Associated CPT or HCPC codes billed to the account.

Effective Date

Effective date of the current contract rates.

Error Code

Reason for rejection or return, if applicable.

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.

High Volume Provider

Indicates if the provider is a high volume provider.

Provider Locality Code

Locality code assigned to the provider.

Provider Number / NPI

Provider’s tax ID number or 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).

Service Date

Date the service was rendered.

Total Expected Reimbursement

The calculated reimbursement based on the predefined contract terms and conditions, service type definitions in the system, the repriced claims data, and CHIRP Increase.

Total Reimbursement

Displays the combined sum of ASC Reimbursement, ASC High Volume Reimbursement, and CHIRP Reimbursement.

When the Billed Charges are less than the ASC Reimbursement, the Total Reimbursement displays the total values of the Billed Charges, the High-Volume Reimbursement, and the CHIRP Reimbursement.