View the Texas Medicaid Outpatient Expected Reimbursement Detail
Use the following procedure to view the Texas Medicaid Outpatient Expected Reimbursement Detail. If Reimbursement Advice (RA) information is available from Medicaid this page displays the RA data as well as the calculated totals from Contract Manager. Discrepancies between the two display at both the claim level and the line item level.
Note: If the Expected Reimbursement Detail is incomplete, click a Service Type link.
Procedure
- Access the Expected Reimbursement Detail page for a Texas Medicaid Outpatient account. For more information, refer to View the Expected Reimbursement Details .
- Review the expected reimbursements.
- 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.
Field Descriptions – Texas Medicaid Outpatient
The following table describes the fields on the Expected Reimbursement Detail page for Texas Medicaid Outpatient claims.
|
Field |
Description |
|
Basic Payment |
Calculated payment based on CTC methodology |
|
Billed Charges |
The total charges incurred for the claim or set of claims that have been repriced |
|
Billed Units |
Number of units billed |
|
CHIRP Add-On |
Displays the Comprehensive Hospital Increase Program (CHIRP) add-on amount |
|
CHIRP Rate |
Displays the Comprehensive Hospital Increase Program (CHIRP) rate |
|
CPT / HCPC Codes & Modifiers |
Associated CPT or HCPC codes billed to the account |
|
CTC Ratio |
Charge-to-cost ratio |
|
Children's Low Volume Percentage |
Displays the current allowable rate. (This column only displays if your facility is set up as a childern's hospital.) |
|
Children's High Volume Percentage |
Displays the current allowable rate. (This column only displays if your facility is set up as a childern's hospital.) |
|
Effective Date |
Effective date of the current contract rates |
|
Error Code |
Reason for rejection or return, if applicable |
|
Fee Schedule Payment |
Total reimbursement from a fee schedule (Lab, DMEPOS, PEN and therapies) |
|
Gross Charges |
The total charges incurred for the claim or set of claims that have been repriced |
|
High / Low Volume Percentage |
The reimbursement percentage paid based on the provider’s volume and location. The percentage rates for high and low volume providers are different for rural facilities and facilities in Rockwall county than they are for the rest of the state. |
|
Paid Units |
Quantity paid |
|
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) |
|
Rev Code |
Revenue code |
|
Service Date |
Date the service was rendered |
|
State ID |
Two-letter state identifier used by Medicare (e.g., TX) |
|
Total 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 in accounts are calculated by the system at the full DRG payment, but these accounts are sometimes reimbursed as a per diem calculation. If the admit source (UB92, FL20 or UB04, FL15) equals 04, the total reimbursement value is a hyperlink that opens the Account Override Verification page to provide quick access to overriding the account when necessary. |
|
Universal Mean |
Mean dollar value for the provider accounts |