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1 | CPEE_v1_Build_7.zip\CPEE_v1_Build_7\Build 7 - Sprint 15\CPE001-124 Assistant Surgeons. PL Zip in the CMAC Payment Methodology for PA or NP as an Assistant-at-Surgery | Unit Test - User Story CPE001-124.docx | Tue Apr 24 15:18:40 2018 UTC |
2 | CPEE_v1_Build_7.zip\CPEE_v1_Build_7\Build 7 - Sprint 15\CPE001-124 Assistant Surgeons. PL Zip in the CMAC Payment Methodology for PA or NP as an Assistant-at-Surgery | Unit Test - User Story CPE001-124.docx | Tue Apr 24 18:34:34 2018 UTC |
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1 | Unit Test - User Sto ry CPE001- 124 | |
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3 | Assistant Surgeons. PL Zip in the CMAC P ayment Met hodology f or PA or N P as an As sistant-at -Surgery | |
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5 | The system to use th e PL Zip i n the CMAC Payment M ethodology for PA or NP as an Assistant- at-Surgery in all Co rrespondin g Types of Coverage for the Co ordination of Benefi t of Prima ry, Second ary and Te rtiary for CHAMPVA\S B Manual a nd EDI Out patient Cl aims. | |
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7 | Not to exc eed 65% of the allow able amoun t, which i s currentl y 16% of t he allowab le amount. | |
8 | ||
9 | PA - Certi fied Physi cian Assis tant, | |
10 | NP- Certif ied Nurse Practition er, | |
11 | AS - Assis tant Surge on | |
12 | ||
13 | Notes for all the su rgery scen arios (inc luding mul tiple and assistant) : | |
14 | When multi ple surgic al procedu res are pe rformed du ring the s ame operat ive sessio n, benefit s shall be limited t o the less er of the total bill ed charge or the sum of 100-pe rcent of t he allowab le amount for the ma jor surgic al procedu re and 50- percent o f the allo wable amou nt for the other pro cedures. The major procedure is that pr ocedure fo r which th e allowabl e amount i s greatest . If multi ple surgic al procedu res involv e the fing ers or toe s, benefit s for the first surg ical proce dure is co vered at o ne-hundred (100%) pe rcent of t he allowab le amount; the secon d procedur e at fifty (50%) per cent allow able amoun t; and the third and subsequen t procedur es at twen ty-five (2 5%) percen t allowabl e amount. | |
15 | Assistant Surgeons. When a pro cedure is submitted with an as sistant su rgeon modi fier (80, 81, or 82) , claim re view softw are, AI (A rtificial Intelligen ce) determ ines wheth er that pr ocedure al ways, some times, or never requ ires an as sistant su rgeon. If the deter mination i s always, the modifi ed code wi ll pay, if the deter mination i s never, t he modifie d code wil l reject, if the det ermination is someti mes, clini cal review of the pr ocedure is necessary . | |
16 | The allowa ble amount for an as sistant su rgeon (whe re such se rvices are covered) will be th e lower of the bille d charge o r sixteen (16%) perc ent of the prevailin g charge f or the sur gery perfo rmed. Whe n an assis tant surge on is invo lved in mu ltiple sur geries, th e same pro cedures fo r determin ing reimbu rsement fo r the prim ary surgeo n are be u sed in det ermining r eimburseme nt for ass istant sur geons. PA (Certified Physician Assistant ), and NP (Certified Nurse Pra ctitioner) . The allo wable amou nt for a P A and NP s ervices fo r other th an assista nt-at-surg ery may no t exceed 8 5-percent of the all owable amo unt for a comparable service r endered by a physici an perform ing the se rvice in a similar l ocation. T he allowab le amount for PA and NP servic es perform ed, as an assistant- at-surgery may not e xceed 65-p ercent of the allowa ble amount for a phy sician ser ving as an assistant surgeon, which is c urrently s ixteen (16 %) of the allowable amount. | |
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24 | Convert IC D-9-CM Dia gnosis 844 .2 to ICD- 10-CM | |
25 | ICD-9-CM 8 44.2 conve rts approx imately to : | |
26 | •2018 ICD- 10-CM S83. 509A Sprai n of unspe cified cru ciate liga ment of un specified knee, init ial encoun ter | |
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32 | OU TPATIENT D ATA SCREEN | |
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34 | DOS: MAR 1 9, 2018 Tota l Charges: $ 10000.0 0 TOTA L PR BAL:$ 2000.00 | |
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36 | DXS PXS/NDC MOD IFIERS UN T/QTY DESC RIPTION AMOUNT P/R BAL | |
37 | 1 S83.509 A SPRA IN UNS C | |
38 | 2 29888 AS 1 KNEE ARTHROS 5000.00 1000.00 | |
39 | 3 29888 AS 1 KNEE ARTHROS 5000.00 1000.00 | |
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51 | PDI: 20180 6203000190 Page #: 1 Img #: 1 Assign ment: | |
52 | Vendor: IN TRALIGN CA PHYS ASSI STANTS Ben eficiary: SANDER-SIR OIS,MARYKA Y | |
53 | [OH I PAYMENTS E/E SCREE N] | |
54 | OHI TOC: 1 - NO OHI OHI Edit TOC: | |
55 | - -- Primary OHI --- Add'l OHIs | |
56 | DOS SVCS/ NDC Bil led Amt Paid P/R Paid P/R Bal | |
57 | 2 03/21/ 18 29 888-AS 5000.00 1000.00 1000.00 | |
58 | 3 03/21/ 18 29 888-AS 5000.00 1000.00 1000.00 | |
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65 | TOTAL S 10 ,000.00 0.00 2,000.00 0.00 2,000.00 | |
66 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
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72 | * * WARNING - OHI was not entere d on Benef iciary ID screen. ** | |
73 | 1) Cont Ed t 2) Next Scr 3) E nt Ttls 4 ) OHI Edit 5) OHI H ist 6) ET DOS | |
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79 | PDI# 20180 6203000190 Related C laims: | |
80 | ||
81 | No. Claim # RO Cl # Bene Typ Vendor D.O.S D/C | |
82 | --- ----- -- ----- -- ---- ---------- - --- ---------- ------- --- --- | |
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84 | 1) RLT82 24 SAND ER-SIROIS, M OUT INTRALIGN 3/19/20 18 | |
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93 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
94 | Select: 1 ) Edit | |
95 | 2 ) Continue | |
96 | 3 ) Process New Page | |
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101 | DUZ: 58819 6 Health A dministrat ion Center Page: 1 | |
102 | Date: MAR 21, 2018 Post-Pro cessing Cl aim Report | |
103 | Time: 919 | |
104 | ||
105 | PDI: 201806203 000190- BATCH: Cl aim #: RLT 8224 | |
106 | EIN: 710890443 - -cc S tatus: Pay ment Req. | |
107 | Program: CHAMPVA | |
108 | Vendor: INTRALIGN CA PHYS A S Type: Out patient | |
109 | Pay Prov?: Yes Ser/Admis Date: MAR 19,2018 | |
110 | Sponsor: SIROIS,PA UL D Comp. Date: | |
111 | Bene: SANDER-SI ROIS,MARYK AY POS: OUT PATIENT HO S | |
112 | Bene Sex: F Bene DOB: 05/27/63 P L ZIP: 198 03 | |
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117 | Press <RET URN> to co ntinue, <^ > to exit. | |
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119 | DX's/Px's/ NDC's P/L Unt/Qty Total Chg TotalAA Mcai d O HI #1 PD OHI #1 P R Deduc t Pa yments AI Reas | |
120 | AlwUnt Chg/Unt AA/Unt A ddl OHI OHI PR B al Cst S hare | |
121 | ---------- --------- ------- ---------- - ------- ---- ---- ------- - ---------- -------- --- ----- ------ -- --------- -- ---- | |
122 | S83.509A 1 AC | |
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124 | 29888-AS 1 5,000.0 0 10 8.66 4,000.00 1,000 .00 0.00 108.66 AC | |
125 | 1 5,000.0 0 10 8.66 0.00 | |
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127 | 29888-AS 1 5,000.0 0 5 4.33 4,000.00 1,000 .00 0.00 54.33 AC | |
128 | 1 5,000.0 0 5 4.33 0.00 | |
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130 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
131 | Totals: 10,000.0 0 16 2.99 8,000.00 2,000 .00 0.00 162.99 | |
132 | 0.00 | |
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135 | Press <RET URN> to Co ntinue, <^ > to exit. | |
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139 | Tot al Charges Billed: 10,00 0.00 CITI Maximum Re imbursemen t Rate: N/ A | |
140 | Calculated Allowable Amount: 16 2.99 MEDICAID Amount: N/ A | |
141 | A mount Appl ied to Ded uctible: 0.00 Am ount Paid by TPL: N/ A | |
142 | Cos t Share Cr edited to Cat Cap: 0.00 Amoun t Reversed from Dedu ctible: N/ A | |
143 | Amount Paid by O ther Insur ance(s): 8,00 0.00 Am ount Rever sed from C at Cap: N/ A | |
144 | Pa tient Resp onsibility Amount: 2,00 0.00 Amount Red uced from Previous P ayment: N/ A | |
145 | Amount Pa id by Bene ficiary to Vendor: 0.00 L ast PDI Pa yment Diff erence: 0.0 0 | |
146 | Total Amount to be PAID o n claim: 16 2.99 Total Paym ent for Cu rrent PDI# 201806203 000190: +162.9 9 | |
147 | Amou nt PAID to Vendor: 16 2.99 | |
148 | Amount PA ID to Bene ficiary: 0.00 | |
149 | ||
150 | Press <RET URN> to Co ntinue, <^ > to exit. | |
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153 | CHAM PVA Benefi ciary Dedu ctible 201 8: 50.00 (satisfied ) | |
154 | CHAMPVA F amily Dedu ctible 201 8: 50.00 | |
155 | CHAMP VA Family Catastroph ic Cap 201 8: 505.86 | |
156 | ||
157 | Press <RET URN> to Co ntinue, <^ > to exit. | |
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160 | ||
161 | Actions fo r Claim: | |
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163 | 1) ASQ (Complete) 2) SNA CAPPS (Pen ding Batch Process) | |
164 | 3) Clai mCheck (Co mplete) | |
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167 | Claim Reas ons: 319 - CFR 17.272(B)( 3) REQUIRE S PROVIDER TO ACCEPT CHAMPVA A LLOWABLE A S FULL PAY MENT. | |
168 | 322 - COST SHARE FOR CLAIM MAY NOT ALWAY S BE PATIE NT LIABILI TY; OHI / CAT CAP MA Y IMPACT. | |
169 | 356 - REMI NDER - MAI L CLAIMS T O: CHAMPVA , PO Box 4 69064, DEN VER, CO 80 246-9064 | |
170 | 371 - WHEN RESUBMITT ING CLAIMS YOU MUST ATTACH THE CHAMPVA E OB FOR PRO PER PROCES SING. | |
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173 | Press <RET URN> to co ntinue. | |
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180 | C MAC Data | |
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183 | Z ip Code: 19803 | |
184 | CHA MPUS Local ity No.: 316 | |
185 | C PT Code: 29888 | |
186 | CMAC Da ta Year: 18 | |
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188 | F acility Non-Facili ty Profe ssional Technical | |
189 | - Physicia n $ 1044.80 $ 1044.80 | |
190 | - Non-Phys ician $ 888.08 $ 888.08 | |
191 | ||
192 | <RETURN> t o continue : | |
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196 | HADR1TSVR: HADTST>W 1 044.8*.16* .65 | |
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198 | 108.6592 | |
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200 | HADR1TSVR: HADTST> | |
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205 | HADR1TSVR: HADTST>W 1 08.6592*.5 | |
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207 | 54.3296 | |
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