Pennsylvania

To calculate a Pennsylvania Medicaid claim at 100% of the state regulation rates, use the default settings. The required fields are identified on the image below. Optional fields are either applied or not applied based on the specific contract language.

Note: Refer to the contract to determine the options to select and the values to enter.

The following settings are required for Pennsylvania Medicaid managed care contracts.

  • Override Provider Number – Type the preferred provider number.
  • State Code – Defaults to PA (this value cannot be changed).
  • Percent of Reimbursement – This should be set to 100% unless specified otherwise.

The following table describes the fields on the PA tab of the Medicaid - Facility reimbursement tool.

Field

Description

Override Provider Number

Preferred provider number. Up to ten alphanumeric digits.

Override Service Date

Preferred service date. Use MM/DD/YYYY format. Overrides the service date on the claim with the date you enter. You may use the anchor date instead of this option.

State Code

This field defaults to PA, and it cannot be changed.

Do not consume charges

Provides the option not to consume charges. This is used for contract carve outs.

Do not consume units

Provides the option not to consume units. This is used for contract carve outs.

Percent Reimbursement

Three digit percentage amount.

Altered surgery / T & X reimbursement

Provides the option to activate alternative logic to handle limitations with surgeries, T-codes, X-codes, and Diagnostic Medical Services (DMS).

Ignore OP SURG Mod

Provides the option to activate alternative logic to ignore OP SURG modifier.

Pay Global Rate if Modifier Not Billed

Provides the option to activate alternative logic to pay the global rate if the modifier is not billed.

Additional ER Diagnostic Medical Service Code

Provides the option to activate alternative logic for additional ER Diagnostic Medical Service code.

Only Reimburse ER with a Provider Specific value of 16

Provides the option to activate alternative logic to only reimburse ER with a provider specific value of 16.

Exclude Modifier 91

When Exclude Modifier 91 is selected, the following logic applies:

  • If a Procedure Code with Modifier 91 is billed on a claim and has the same date of service as a previously billed Similar Procedure Code, the Procedure Code billed with Modifier 91 reimburses 0.00.
  • If a Procedure Code with Modifier 91 is billed on a claim and has a different date of service as a previously billed Similar Procedure Code, the Procedure Code billed with Modifier 91 reimburses at the Fee Schedule Rate.
  • If a Procedure Code with Modifier 91 is billed on a claim but there is no similar Procedure code without Modifier on the same claim, the Procedure Code billed with Modifier 91 reimburses 0.00.

Managed Care OP Surgery Reimbursement

Provides the option to activate alternative logic to calculate using the Managed Care OP Surgery Reimbursement.

Use All Modifiers

Provides the option to activate alternative logic allow pricing modifiers listed in the second modifier position on the UB04 to be used for pricing.