Workers’ Compensation - Pennsylvania

The Workers’ Compensation - Pennsylvania tool calculates Workers’ Compensation claims based on facility / state-specific information. The Override Provider Number field is required. 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 RCC table allows customers to price revenue codes to a percent of billed charges when the reimbursement is pricing to 0.00.
  • The customer provides the Revenue Codes, and a Percentage, which calculate at percent of Billed Charges.
  • The Payment Indicator is D for these line items.
  • The Clinical lab listed on the Part B table takes precedent over the Service Codes listed in the Cost Allowance Files (CAF).
  • The payment indicator is B on these claims.
  • These are customer provided.
  • The customer needs to send files with a Salesforce case.
  • Pennsylvania Workers Comp publishes the CAF files quarterly.
  • These are facility specific.
  • Customer must state the total numeric characters desired for the Service Codes. See the following examples:
    • Service Code 4561 must be billed as 4561, if loaded with only four characters.
    • If Service Code 4561 is to be billed as 00004561, the request needs to be for eight characters.
  • The payment indicator is A on these claims.
  • Items with revenue codes beginning with 025 or 063, the line-item charges are multiplied by the ratio of the costs-to-charges (RCC) and then multiplied by 1.13.
  • The unique Medicare Provider Number bases the RCC.
  • The RCC amount is found in the Provider table.
  • The payment indicator is C for these claims.

The following table describes the fields on the Workers’ Compensation - Pennsylvania reimbursement tool.

Field

Description

(Patient Type)

Patient type assigned to the account: Inpatient/Outpatient

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.

Replace Blank Date with Service Through

Provides the option to replace a blank service date with the service through date.

Truncate (do not round) total

Provides the option to truncate the total. For example if a total is 100.85, it is truncated to 100. If left unchecked, the total will round to 101.