As we transition to our next generation platform, you will see a change in the display of reimbursement for inpatient stays for claims processed on the new platform — depending on the payment methodology (i.e., per diem or diagnosis related group [DRG]).
Inpatient per diem claims
Regardless of the claim platform, reimbursement is displayed on two or more separate payment lines, as shown in the example below.
|
Claim ID |
Claim Line |
Rev Code |
Units of Service |
Charges |
Contracted Rate |
Reimbursement |
| 0011 | 1 | 0171 | 1 | $3,000 | $47 per diem | $884.00 |
| 0011 | 2 | 0174 | 1 | $6,000 | $3,489 per diem | $1,768.00 |
| 0011 | 3 | 0300 | 5 | $1,000 | - | $294.67 |
| 0011 | 4 | 0636 | 10
| $2,000 | - | $589.33 |
| | | |
Totals |
$12,000 |
$3,536.00 |
$3,536.00 |
Inpatient DRG claims
-
For claims processed on the existing platform.
Reimbursement is spread across
all claim lines by multiplying the contracted rate by the line charges divided by the total charges. Example using line 1: 20,000 * (10,000 / 63,000):
|
Claim ID |
Claim Line |
Rev Code |
Units of Service |
Charges |
Contracted Rate |
Reimbursement |
| 0011 | 1 | 0120 | 2 | $10,000 | $20,000 per Case | $3,174.60 |
| 0011 | 2 | 0200 | 3 | $20,000 | | $6,349.21 |
| 0011 | 3 | 0210 | 5 | $30,000 | | $9,523.81 |
| 0011 | 4 | 0300 | 1 | $1,000 | | $317.46 |
| 0011 | 5 | 0636
| 100 | $2,000 | | $634.92 |
| | | |
Totals |
$63,000 |
|
$20,000.00 |
-
For claims processed on the next generation platform.
Reimbursement is spread across
ROOM AND BOARD claim lines only by multiplying the contracted rate by the line covered units divided by the total room and board units. Example using line 1: 20,000 * (2 / 10):
|
Claim ID |
Claim Line |
Rev Code |
Units of Service |
Charges |
Contracted Rate |
Reimbursement |
| 0011 | 1 | 0120 | 2 | $10,000 | $20,000 per Case | $4,000.00 |
0011
| 2 | 0200 | 3 | $20,000 | | $6,000.00 |
| 0011 | 3 | 0210 | 5 | $30,000
| | $10,000.00 |
| 0011 | 4 | 0300 | 1 | $1,000 | | $0.00 |
| 0011 | 5 | 0636 | 100 | $2,000 | | $0.00 |
| | | |
Totals |
$63,000 |
|
$20,000.00 |
Visit our dedicated Platform Transition page to stay informed of our ongoing transition.