Title of Module

Title of Module

-Title of Module

This document explains the process of calculating an ED service rate. For Alpha to calculate the HRCCR rate correctly, the HRCCR service must be in the provider’s contract with a service specific rate. All ED claims EXCEPT Lab and Professional services use the Hospital RCC Rate.

  1. Checks Provider Contract for HRCCR and a rate
  1. HRCCR: Hospital Ratio of Costs to Charges Rate
  2. Procedure code “HRCCR” added to contract specific rate tile within the contract. (.65 of the ED service rate used in the example on 3rd page.)
  1. DOS must be within the providers contract and ED service rate effective/end dates
  1. If HRCCR service is not in the provider’s contract but is a Lab or 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

  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

5.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)

TECH NOTES: [asp_process_ed_claims] has the logic for determining the service rate.

-- Get rate from service matrix, only for PF, LB and MS

UPDATE t

SET rate = esm.rate

FROM

#temp_ed_adjs t, dbo.tb_ed_service_matrix esm

WHERE

esm.ed_cat_Cd IN ('LB','PF', ‘MS’)

AND t.pc_id = esm.pc_id

AND esm.active = 1

AND t.clm_dos BETWEEN esm.eff_dt AND ISNULL(esm.end_dt,'12/31/2099')

--All ED claims, with the exception of lab, pharmacy, and professional services,

--are to be paid by Ratio of Cost to Charge (RCC). In state provider only.

--Allowable charge x hospital RCC x 80%

--Allowable charge = lesser of fee billed or fee from Medicaid schedule

--Fee billed should be adjusted by third party liability

--Attached in another document is the rcc for each hospital in NC

--Hospital RCC = each hospital has their own RCC which Smoky will keep updated

UPDATE #temp_ed_adjs SET rate = (clm_amt - cob_amt) * rate * 0.8

WHERE ed_cat_Cd NOT IN ('LB','PF', ‘MS’)

AND ISNULL(clm_amt,0) > ISNULL(cob_amt,0)

UPDATE #temp_ed_adjs SET rate = 0

WHERE ed_cat_Cd NOT IN ('LB','PF', ‘MS’)

AND ISNULL(clm_amt,0) <= ISNULL(cob_amt,0)

--ED claims - lab. In state provider only.

--Allowable charge x 100%

--Allowable charge = lesser of fee billed or fee from Medicaid schedule

--Fee billed should be adjusted by third party liability

--ED claims -pharmacy. In state provider only.

--Allowable charge x 100%

--Allowable charge = lesser of fee billed or fee from Medicaid schedule

--Fee billed should be adjusted by third party liability

--For ED claims - professional services (physicians and specialists). In state provider only.

--Allowable charge is lesser of fee billed or Medicaid approved rate schedule

--Fee billed should be adjusted by third party liability

--Medicaid fee schedule is the facility fee values for these claims.

UPDATE #temp_ed_adjs SET rate = (clm_amt - cob_amt)

WHERE ed_cat_Cd IN ('LB','PF', ‘MS’)

AND rate > ISNULL(clm_amt,0) - ISNULL(cob_amt,0) -- EZ 05/06/13 to approve at lesser of MCD rate or billed amount

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