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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; PL-ZIP 89047.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; PL-ZIP 89047.docx | Tue Apr 24 18:08:26 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 | OU TPATIENT D ATA SCREEN | |
18 | ||
19 | DOS: MAR 0 9, 2018 Tota l Charges: $ 5000.0 0 TOTA L PR BAL:$ 0.00 | |
20 | ||
21 | DXS PXS/NDC MOD IFIERS UN T/QTY DESC RIPTION AMOUNT P/R BAL | |
22 | 1 T81.4XX A INFE CTION FO | |
23 | 2 B95.62 METH ICILLIN | |
24 | 3 10180 1 COMP LEX DRAI 5000.00 | |
25 | ||
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29 | ||
30 | ||
31 | 1) Exit 2) Change 3) Dele te 4) Ad d 5) Scroll 6 ) Payments | |
32 | Select: Ex it// | |
33 | ||
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45 | ||
46 | [ Edit Claim Data Scre en] | |
47 | ||
48 | ||
49 | PDI# 20180 6403000020 Related C laims: | |
50 | ||
51 | No. Claim # RO Cl # Bene Typ Vendor D.O.S D/C | |
52 | --- ----- -- ----- -- ---- ---------- - --- ---------- ------- --- --- | |
53 | ||
54 | 1) RLT82 48 MURP HY,MARY T OUT AMBULATORY 3/9/201 8 | |
55 | ||
56 | ||
57 | ||
58 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
59 | Select: 1 ) Edit | |
60 | 2 ) Continue | |
61 | 3 ) Process New Page | |
62 | ||
63 | Choose: | |
64 | ||
65 | ||
66 | VENDOR DAT A SCREEN | |
67 | ||
68 | ||
69 | 1 Vend or: AMBUL ATORY SURG CTR OF SO NV | |
70 | 2 Tax ID: 86108 1788 | |
71 | 3 Ad dress Line 1: 3820 S HUALAPAI WAY | |
72 | 4 Ad dress Line 2: STE 1 00 | |
73 | 5 Ci ty: LAS V EGAS | |
74 | 6 Sta te: NEVAD A | |
75 | 7 Z ip: 89147 5733 | |
76 | 8 CMAC Co de: 1 | |
77 | 9 Vendor Pa ge: | |
78 | 10 Assignme nt: Yes | |
79 | 11 P CN: | |
80 | 12 T OB: 111 | |
81 | 13 Phone Numb er: | |
82 | 14 PL Z IP: 89047 | |
83 | ||
84 | ||
85 | ||
86 | ||
87 | ||
88 | ||
89 | DUZ: 58819 6 Health A dministrat ion Center Page: 1 | |
90 | Date: MAR 23, 2018 Post-Pro cessing Cl aim Report | |
91 | Time: 858 | |
92 | ||
93 | PDI: 201806403 000020- BATCH: Cl aim #: RLT 8248 | |
94 | EIN: 861081788 - -A1 S tatus: Pay ment Req. | |
95 | Program: CHAMPVA | |
96 | Vendor: AMBULATOR Y SURG CTR Type: Out patient | |
97 | Pay Prov?: Yes Ser/Admis Date: MAR 9,2018 | |
98 | Sponsor: MURPHY,GE ORGE J Comp. Date: | |
99 | Bene: MURPHY,MA RY T POS: AMB ULATORY SU R | |
100 | Bene Sex: F Bene DOB: 01/02/54 P L ZIP: 890 47 | |
101 | ||
102 | ||
103 | ||
104 | ||
105 | Press <RET URN> to co ntinue, <^ > to exit. | |
106 | ||
107 | 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 | |
108 | AlwUnt Chg/Unt AA/Unt A ddl OHI OHI PR B al Cst S hare | |
109 | ---------- --------- ------- ---------- - ------- ---- ---- ------- - ---------- -------- --- ----- ------ -- --------- -- ---- | |
110 | T81.4XXA 1 AC | |
111 | ||
112 | B95.62 1 AC | |
113 | ||
114 | 10180 1 5,000.0 0 56 3.00 0.00 422.25 AC | |
115 | 1 5,000.0 0 56 3.00 140.75 | |
116 | ||
117 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- ----- | |
118 | Totals: 5,000.0 0 56 3.00 0.00 422.25 | |
119 | 140.75 | |
120 | ||
121 | ||
122 | Press <RET URN> to Co ntinue, <^ > to exit. | |
123 | ||
124 | ||
125 | ||
126 | Tot al Charges Billed: 5,00 0.00 CITI Maximum Re imbursemen t Rate: N/ A | |
127 | Calculated Allowable Amount: 56 3.00 MEDICAID Amount: N/ A | |
128 | A mount Appl ied to Ded uctible: 0.00 Am ount Paid by TPL: N/ A | |
129 | Cos t Share Cr edited to Cat Cap: 14 0.75 Amoun t Reversed from Dedu ctible: N/ A | |
130 | Amount Paid by O ther Insur ance(s): N/A Am ount Rever sed from C at Cap: N/ A | |
131 | Pa tient Resp onsibility Amount: N/A Amount Red uced from Previous P ayment: N/ A | |
132 | Amount Pa id by Bene ficiary to Vendor: 0.00 L ast PDI Pa yment Diff erence: 0.0 0 | |
133 | Total Amount to be PAID o n claim: 42 2.25 Total Paym ent for Cu rrent PDI# 201806403 000020: +422.2 5 | |
134 | Amou nt PAID to Vendor: 42 2.25 | |
135 | Amount PA ID to Bene ficiary: 0.00 | |
136 | ||
137 | Press <RET URN> to Co ntinue, <^ > to exit. | |
138 | ||
139 | ||
140 | CHAM PVA Benefi ciary Dedu ctible 201 8: 0.00 | |
141 | CHAMPVA F amily Dedu ctible 201 8: 0.00 | |
142 | CHAMP VA Family Catastroph ic Cap 201 8: 290.00 | |
143 | ||
144 | Press <RET URN> to Co ntinue, <^ > to exit. | |
145 | ||
146 | ||
147 | ||
148 | Actions fo r Claim: | |
149 | ||
150 | 1) SNA CAPPS (Pen ding Batch Process) 2) Clai mCheck (Co mplete) | |
151 | ||
152 | ||
153 | Claim Reas ons: 319 - CFR 17.272(B)( 3) REQUIRE S PROVIDER TO ACCEPT CHAMPVA A LLOWABLE A S FULL PAY MENT. | |
154 | 322 - COST SHARE FOR CLAIM MAY NOT ALWAY S BE PATIE NT LIABILI TY; OHI / CAT CAP MA Y IMPACT. | |
155 | 356 - REMI NDER - MAI L CLAIMS T O: CHAMPVA , PO Box 4 69064, DEN VER, CO 80 246-9064 | |
156 | 371 - WHEN RESUBMITT ING CLAIMS YOU MUST ATTACH THE CHAMPVA E OB FOR PRO PER PROCES SING. | |
157 | ||
158 | ||
159 | Press <RET URN> to co ntinue. | |
160 | ||
161 | ||
162 | Select AMB Surg Menu <TEST ACC OUNT> Opti on: APG A SC Payment Group | |
163 | ||
164 | Select CHA MPVA ASC P AYMENT GRO UPS CPT-4 CODE: 1018 0 | |
165 | ||
166 | DEVICE: SSH VIRTUA L TERMINAL Right Margin: 80 // | |
167 | CHAMPVA AS C PAYMENT GROUPS Lis t MAR 23, 2018@09:0 0 PAGE 1 | |
168 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
169 | ||
170 | ||
171 | CPT-4 CODE : 10180 | |
172 | BEGIN EFFE CTIVE DATE : NOV 01, 1994 PAYMENT GR OUP: 4 | |
173 | DUZ: THO MPSON,DORT HEA P DATE CHANG ED: NOV 16 , 2017 | |
174 | ||
175 | ||
176 | Select CHA MPVA ASC P AYMENT GRO UPS CPT-4 CODE: | |
177 | ||
178 | ||
179 | DEVICE: SSH VIRTUA L TERMINAL Right Margin: 80 // | |
180 | CHAMPVA AM B ZIP CODE S List MAR 23, 2018@09:1 1 PAGE 1 | |
181 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
182 | ||
183 | ||
184 | ZIP CODE: 89047 STATE POST AL ABBREV: NV | |
185 | DATE: NOV 01, 1994 MSA CODE: 9932 | |
186 | ||
187 | ||
188 | Select CHA MPVA AMB Z IP CODES: | |
189 | ||
190 | Correct pa yment for Group 4 | |
191 | ||
192 | Select CHA MPVA ASC P AYMENT RAT ES MSA COD E: 9932 | |
193 | ||
194 | DEVICE: SSH VIRTUA L TERMINAL Right Margin: 80 // | |
195 | CHAMPVA AS C PAYMENT RATES List MAR 23, 2018@09:1 3 PAGE 1 | |
196 | ---------- ---------- ---------- ---------- ---------- ---------- ---------- ---------- | |
197 | ||
198 | ||
199 | BEGIN EFFE CTIVE DATE : NOV 01, 2017 TERMINATIO N DATE: OC T 31, 2018 | |
200 | DUZ: THO MPSON,DORT HEA P LAST DATE CHANGED: O CT 23, 201 7 | |
201 | DOLLAR RAT E FOR GROU P: 000212 | |
202 | DOLLAR RAT E FOR GROU P: 000371 | |
203 | DOLLAR RAT E FOR GROU P: 000511 | |
204 | DOLLAR RAT E FOR GROU P: 000563 | |
205 | DOLLAR RAT E FOR GROU P: 000700 | |
206 | DOLLAR RAT E FOR GROU P: 000838 | |
207 | DOLLAR RAT E FOR GROU P: 000928 | |
208 | DOLLAR RAT E FOR GROU P: 001055 | |
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