ED Service Matrix

Emergency Services are services that are performed in an emergency room. These claims normally come in to MCS as IF or IP, but can be PP or PF if the POS is Emergency Room or has a bill type of 013x.

MCSidentifies Emergency room services by using the following logic.

  • POS of Emergency Room (except for professional claims with service code H2011)
  • The revenue codes for ED (emergency room) claims are between 0450-0459 with a bill type of 013x. 837i / UB04 claims submitted with bill type 0130 - 0139 will be treated as ED claims.
  • ED claims cannot have R&B (room & board) codes. If they do, then they will be denied with reason code (107 - invalid bill type). If a claim has R&B, it will become an IP claim and 013x bill type is invalid.
  • ED claims will pend for Manual Review by MCO staff.

To navigate to the ED Service Matrix you will go to Menu > Finance > ED Service Matrix. Once you are in the modulethe first 25 ED services will show automatically. You can search for more by entering the code into the EDService field and clicking Search.

When you’ve found the code you’d like to update the rate for, click on the 3, then the Update button.

By clicking the “Update” button you can make the nessacary edits or changes to the existing record.

Clicking the Create button you are able to input a new record in the ED Service Matrix.

This button takes you to a similar screen, where you’re able to enter information for codes that are not currently in the ED service matrix.

  • Code - the procedure code, or service rendered for reimbursement
  • Modifier 1-4 -fields used to identify the service modifier(s) when one is submitted on the claim.
  • ED Service – Emergency Department procedure codes
  • Type (dropdown)
  • ED Service
  • ED Category (dropdown)
  • LB - lab
  • MS - miscellaneous
  • PF - professional
  • PH - pharmacy
  • Rate – the intended amount of money to be paid for the service
  • Effective Date – beginning date
  • End Date – termination date
  • Active (check box) – if the box has a check in it then it is currently in use
  • Save (button) – records the record for use in the system
  • Cancel (button) – does not save or keep the updated changes in the system

Calculations:

If HRCCR service is not in the provider’s contract but is a Labor Professional code; then Alpha uses the ED Service matrix Rate.

Code type is determined in tb_ed_service_matrix, field ed_cat_cd as either:

(LB) Lab

(PF) Professional

(MS) Miscellaneous

--ED Service Matrix Query

SELECT e.pc_id, p.pc_code, p.pc_mod1, p.pc_mod2, e.rate, e.eff_dt, e.end_dt, e.ed_cat_cd, c.ed_cat_desc, e.pc_code, e.pc_desc

FROM tb_ed_service_matrix e, tb_proc_codes p, tb_ED_service_categories c

WHERE p.pc_id = e.pc_id

AND c.ed_cat_cd = e.ed_cat_cd

AND e.active = 1

When the service is not LB or PF the calculation is (clm_amt – cob_amt) * rate * 0.8. All other ED services will fall under the MS category and will be calculated by paid RCC* 0.8 of the rate

If it is one of these category codes then it’s the lesser of either the MCD rate or the billed amount calculated as rate = (clm_amt – cob_amt)