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# | Location | File | Last Modified |
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1 | CPEE_v1_Build_7.zip\CPEE_v1_Build_7\Build 7 - Sprint 15\CPE001-113 ASC Freestanding Facility Prospective Payment Methodology | Unit Test - User Story CPE001-113.docx | Tue Apr 24 15:18:40 2018 UTC |
2 | CPEE_v1_Build_7.zip\CPEE_v1_Build_7\Build 7 - Sprint 15\CPE001-113 ASC Freestanding Facility Prospective Payment Methodology | Unit Test - User Story CPE001-113.docx | Tue Apr 24 17:57:24 2018 UTC |
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1 | Unit Test - User Sto ry CPE001- 113 | |
2 | ||
3 | ASC Freest anding Fac ility Pros pective Pa yment Meth odology | |
4 | ||
5 | Effective with servi ces provid ed on or a fter Novem ber 1, 199 4, the CHA MPVA reimb ursement m ethodology | |
6 | for facili ty charges associate d with pro cedures pe rformed in an ambula tory surge ry setting | |
7 | (includes both hospi tal based settings a nd freesta nding surg ical cente rs) was ch anged to a | |
8 | prospectiv e payment system. Th is methodo logy, mode led after Medicare, is based o n the cate gorization | |
9 | of certain ambulator y surgical procedure s into ele ven paymen t groups. Each paym ent group is | |
10 | establishe d on a cos t-basis an d adjusted for area labor cost s based on the MEI ( Medicare E conomic In dex). | |
11 | NOTE: rela ted servic es, aka an cillary ch arges are allowed as billed fo r hospital based fac ilities | |
12 | and denied for frees tanding fa cilities. We are una ble to uti lize our n ormal CMAC rates for | |
13 | ancillary charges be cause clai m is alrea dy paying under a sp ecial paym ent method olgy = ASC | |
14 | and our cu rrent syst em cannot pay two di fferent pa yment meth odologies under the same claim . | |
15 | ||
16 | ||
17 | PDI: 20180 6303000024 Page #: 1 Img #: 1 Assign ment: | |
18 | Vendor: AM BULATORY S URG CTR OF SO NV Ben eficiary: xxxxHY,MAR Y T | |
19 | [OUTPATIEN T E/E SCRE EN - BILL/ INVOICE] | |
20 | OHI TOC: 1 - NO OHI OHI Edit TOC: | |
21 | DOS POS I CD REV SVCS/ND C MODS UNT/QTY AMOUNT P/R BAL | |
22 | 1 03/10/ 18 ASC T81 .4XXA | |
23 | 2 03/10/ 18 ASC B 95.62 | |
24 | 3 03/10/ 18 ASC 1 0180 1 5000.00 | |
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29 | ||
30 | TOTALS 5,000.00 0.00 | |
31 | COMPLEX DR AINAGE WOU ND | |
32 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
33 | ||
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35 | ||
36 | ||
37 | ||
38 | Select: Ne xt Scr// | |
39 | 1) Cont Ed t 2) Next Scr 3) P rev Scr 4 ) Kill 5) Payme nts 6) Be n Pymt | |
40 | 7) TPL Pym t 8) Del Data 9) O HI Edit 10 ) Restore | |
41 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
42 | ||
43 | ||
44 | ||
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46 | ||
47 | ||
48 | ||
49 | [ Edit Claim Data Scre en] | |
50 | ||
51 | ||
52 | PDI# 20180 6303000024 Related C laims: | |
53 | ||
54 | No. Claim # RO Cl # Bene Typ Vendor D.O.S D/C | |
55 | --- ----- -- ----- -- ---- ---------- - --- ---------- ------- --- --- | |
56 | ||
57 | 1) RLT82 47 xxxx HY,MARY T OUT AMBULATORY 3/10/20 18 | |
58 | ||
59 | ||
60 | ||
61 | ||
62 | ||
63 | ||
64 | ||
65 | ||
66 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
67 | Select: 1 ) Edit | |
68 | 2 ) Continue | |
69 | 3 ) Process New Page | |
70 | ||
71 | Choose: | |
72 | ||
73 | ||
74 | DUZ: 58819 6 Health A dministrat ion Center Page: 1 | |
75 | Date: MAR 22, 2018 Post-Pro cessing Cl aim Report | |
76 | Time: 1541 | |
77 | ||
78 | PDI: 201806303 000024- BATCH: Cl aim #: RLT 8247 | |
79 | EIN: 861081788 - -A1 S tatus: Pay ment Req. | |
80 | Program: CHAMPVA | |
81 | Vendor: AMBULATOR Y SURG CTR Type: Out patient | |
82 | Pay Prov?: Yes Ser/Admis Date: MAR 10,2018 | |
83 | Sponsor: xxxxY,GEO RGE J Comp. Date: | |
84 | Bene: xxxxY,MAR Y T POS: AMBU LATORY SUR | |
85 | Bene Sex: F Bene DOB: 01/02/54 P L ZIP: 890 16 | |
86 | ||
87 | ||
88 | ||
89 | ||
90 | Press <RET URN> to co ntinue, <^ > to exit. | |
91 | ||
92 | 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 | |
93 | AlwUnt Chg/Unt AA/Unt A ddl OHI OHI PR B al Cst S hare | |
94 | ---------- --------- ------- ---------- - ------- ---- ---- ------- - ---------- -------- --- ----- ------ -- --------- -- ---- | |
95 | T81.4XXA 1 AC | |
96 | ||
97 | B95.62 1 AC | |
98 | ||
99 | 10180 1 5,000.0 0 59 7.00 0.00 447.75 AC | |
100 | 1 5,000.0 0 59 7.00 149.25 | |
101 | ||
102 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
103 | Totals: 5,000.0 0 59 7.00 0.00 447.75 | |
104 | 149.25 | |
105 | ||
106 | ||
107 | Press <RET URN> to Co ntinue, <^ > to exit. | |
108 | ||
109 | ||
110 | ||
111 | Tot al Charges Billed: 5,00 0.00 CITI Maximum Re imbursemen t Rate: N/ A | |
112 | Calculated Allowable Amount: 59 7.00 MEDICAID Amount: N/ A | |
113 | A mount Appl ied to Ded uctible: 0.00 Am ount Paid by TPL: N/ A | |
114 | Cos t Share Cr edited to Cat Cap: 14 9.25 Amoun t Reversed from Dedu ctible: N/ A | |
115 | Amount Paid by O ther Insur ance(s): N/A Am ount Rever sed from C at Cap: N/ A | |
116 | Pa tient Resp onsibility Amount: N/A Amount Red uced from Previous P ayment: N/ A | |
117 | Amount Pa id by Bene ficiary to Vendor: 0.00 L ast PDI Pa yment Diff erence: 0.0 0 | |
118 | Total Amount to be PAID o n claim: 44 7.75 Total Paym ent for Cu rrent PDI# 201806303 000024: +447.7 5 | |
119 | Amou nt PAID to Vendor: 44 7.75 | |
120 | Amount PA ID to Bene ficiary: 0.00 | |
121 | ||
122 | Press <RET URN> to Co ntinue, <^ > to exit. | |
123 | ||
124 | ||
125 | CHAM PVA Benefi ciary Dedu ctible 201 8: 0.00 | |
126 | CHAMPVA F amily Dedu ctible 201 8: 0.00 | |
127 | CHAMP VA Family Catastroph ic Cap 201 8: 149.25 | |
128 | ||
129 | Press <RET URN> to Co ntinue, <^ > to exit. | |
130 | ||
131 | ||
132 | ||
133 | Actions fo r Claim: | |
134 | ||
135 | 1) SNA CAPPS (Pen ding Batch Process) 2) Clai mCheck (Co mplete) | |
136 | ||
137 | ||
138 | Claim Reas ons: 319 - CFR 17.272(B)( 3) REQUIRE S PROVIDER TO ACCEPT CHAMPVA A LLOWABLE A S FULL PAY MENT. | |
139 | 322 - COST SHARE FOR CLAIM MAY NOT ALWAY S BE PATIE NT LIABILI TY; OHI / CAT CAP MA Y IMPACT. | |
140 | 356 - REMI NDER - MAI L CLAIMS T O: CHAMPVA , PO Box 4 69064, DEN VER, CO 80 246-9064 | |
141 | 371 - WHEN RESUBMITT ING CLAIMS YOU MUST ATTACH THE CHAMPVA E OB FOR PRO PER PROCES SING. | |
142 | ||
143 | ||
144 | Press <RET URN> to co ntinue. | |
145 | ||
146 | ||
147 | ||
148 | Select AMB Surg Menu <TEST ACC OUNT> Opti on: APG A SC Payment Group | |
149 | ||
150 | Select CHA MPVA ASC P AYMENT GRO UPS CPT-4 CODE: 1018 0 | |
151 | ||
152 | DEVICE: SSH VIRTUA L TERMINAL Right Margin: 80 // | |
153 | CHAMPVA AS C PAYMENT GROUPS Lis t MAR 23, 2018@07:1 1 PAGE 1 | |
154 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
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156 | ||
157 | CPT-4 CODE : 10180 | |
158 | BEGIN EFFE CTIVE DATE : NOV 01, 1994 PAYMENT GR OUP: 4 | |
159 | DUZ: THO MPSON,DORT HEA P DATE CHANG ED: NOV 16 , 2017 | |
160 | ||
161 | ||
162 | Select CHA MPVA ASC P AYMENT GRO UPS CPT-4 CODE: | |
163 | ||
164 | ||
165 | ||
166 | Select AMB Surg Menu <TEST ACC OUNT> Opti on: AZ AM B ZIP Code s | |
167 | ||
168 | Select CHA MPVA AMB Z IP CODES: 89016 | |
169 | ||
170 | DEVICE: SSH VIRTUA L TERMINAL Right Margin: 80 // | |
171 | CHAMPVA AM B ZIP CODE S List MAR 23, 2018@07:1 3 PAGE 1 | |
172 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
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174 | ||
175 | ZIP CODE: 89016 STATE POST AL ABBREV: NV | |
176 | DATE: NOV 01, 1994 MSA CODE: 4120 | |
177 | ||
178 | ||
179 | Select CHA MPVA AMB Z IP CODES: | |
180 | ||
181 | ||
182 | Correct pa yment for Group 4 | |
183 | ||
184 | BEGIN EFFE CTIVE DATE : NOV 01, 2017 TERMINATIO N DATE: OC T 31, 2018 | |
185 | DUZ: THO MPSON,DORT HEA P LAST DATE CHANGED: O CT 23, 201 7 | |
186 | DOLLAR RAT E FOR GROU P: 000224 | |
187 | DOLLAR RAT E FOR GROU P: 000393 | |
188 | DOLLAR RAT E FOR GROU P: 000541 | |
189 | DOLLAR RAT E FOR GROU P: 000597 | |
190 | DOLLAR RAT E FOR GROU P: 000742 | |
191 | DOLLAR RAT E FOR GROU P: 000888 | |
192 | DOLLAR RAT E FOR GROU P: 001326 | |
193 | DOLLAR RAT E FOR GROU P: 001686 | |
194 | DOLLAR RAT E FOR GROU P: 008060 | |
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