NAME TYPE LENGTH
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55. Claim Payment Amount PACK 6
Amount of payment made from the Medicare trust fund for the
services covered by the claim record. Generally, the amount
is calculated by the FI or carrier; and represents what was
paid to the institutional provider, physician, or supplier,
with the exceptions noted below. **NOTE: In some
situations, a negative claim payment amount may be pre-
sent; e.g., (1) when a beneficiary is charged the full
deductible during a short stay and the deductible exceeded
the amount Medicare pays; or (2) when a beneficiary is
charged a coinsurance amount during a long stay and the
coinsurance amount exceeds the amount Medicare pays (most
prevalent situation involves psych hospitals who are paid a
daily per diem rate no matter what the charges are.)
Under IP PPS, inpatient hospital services are paid based on
a predetermined rate per discharge, using the DRG patient
classification system and the PRICER program. On the IP
PPS claim, the payment amount includes the DRG outlier
approved payment amount, disproportionate share (since
5/1/86), indirect medical education (since 10/1/88), total
PPS capital (since 10/1/91). After 4/1/03, the payment
amount could also include a "new technology" add-on amount.
It does NOT include the pass-thru amounts (i.e., capital-
related costs, direct medical education costs, kidney
acquisition costs, bad debts); or any beneficiary-paid
amounts (i.e., deductibles and coinsurance); or any
any other payer reimbursement.
Under IRFPPS, inpatient rehabilitation services are paid
based on a predetermined rate per discharge, using the
Case Mix Group (CMG) classification system and the PRICER
program. From the CMG on the IRF PPS claim, payment is
based on a standard payment amount for operating and
capital cost for that facility (including routine and
ancillary services). The payment is adjusted for wage,
the % of low-income patients (LIP), locality, transfers,
interrupted stays, short stay cases, deaths, and high
cost outliers. Some or all of these adjustments could
apply. The CMG payment does NOT include certain pass-
through costs (i.e. bad debts, approved education
activities); beneficiary-paid amounts, other payer reim-
bursement,and other services outside of the scope of PPS.
Under LTCH PPS, long term care hospital services are paid
based on a predetermined rate per discharge based on the
DRG and the PRICER program. Payments are based on a
single standard Federal rate for both inpatient operating
and capital-related costs (including routine and ancillary
services), but do NOT include certain pass-through costs
(i.e. bad debts, direct medical education, new technologies
and blood clotting factors). Adjustments to the payment
may occur due to short-stay outliers, interrupted stays,
high cost outliers, wage index, and cost of living adjust-
ments.
Under SNF PPS, SNFs will classify beneficiaries using the
patient classification system known as RUGS III. For the
SNF PPS claim, the SNF PRICER will calculate/return the rate
for each revenue center line item with revenue center code =
'0022'; multiply the rate times the units count; and then
sum the amount payable for all lines with revenue center
code '0022' to determine the total claim payment amount.
Under Outpatient PPS, the national ambulatory payment
classification (APC) rate that is calculated for each APC
group is the basis for determining the total claim payment.
The payment amount also includes the outlier payment and
interest.
Under Home Health PPS, beneficiaries will be classified into
an appropriate case mix category known as the Home Health
Resource Group. A HIPPS code is then generated
corresponding to the case mix category (HHRG).
For the RAP, the PRICER will determine the payment amount
appropriate to the HIPPS code by computing 60% (for first
episode) or 50% (for subsequent episodes) of the case mix
episode payment. The payment is then wage index adjusted.
For the final claim, PRICER calculates 100% of the amount
due, because the final claim is processed as an adjustment
to the RAP, reversing the RAP payment in full. Although
final claim will show 100% payment amount, the provider will
actually receive the 40% or 50% payment. The payment may
also include outlier payments.
Exceptions: For claims involving demos and BBA encounter
data, the amount reported in this field may not just
represent the actual provider payment.
For demo Ids '01','02','03','04' -- claims contain
amount paid to the provider, except that special
'differentials' paid outside the normal payment system
are not included.
For demo Ids '05','15' -- encounter data 'claims'
contain amount Medicare would have paid under FFS,
instead of the actual payment to the MCO.
For demo Ids '06','07','08' -- claims contain actual
provider payment but represent a special negotiated
bundled payment for both Part A and Part B services.
To identify what the conventional provider Part A
payment would have been, check value code = 'Y4'. The
related noninstitutional (physician/supplier) claims
contain what would have been paid had there been no
demo.
For BBA encounter data (non-demo) -- 'claims' contain
amount Medicare would have paid under FFS, instead of
the actual payment to the BBA plan.
COMMON ALIAS : REIMBURSEMENT
DB2 ALIAS : CLM_PMT_AMT
SAS ALIAS : PMT_AMT
STANDARD ALIAS : CLM_PMT_AMT
TITLE ALIAS : REIMBURSEMENT
LENGTH : 9.2 SIGNED : Y
COMMENTS :
Prior to Version H the size of this field was S9(7)V99. Als
the noninstitutional claim records carried this field as a l
item. Effective with Version H, this element is a claim lev
field across all claim types (and the line item field has be
renamed.)
SOURCE : CWF
LIMITATIONS :
Prior to 4/6/93, on inpatient, outpatient, and
physician/supplier claims containing a
CLM_DISP_CD of '02', the amount shown as the Medicare
reimbursement does not take into consideration
any CWF automatic adjustments (involving erroneous
deductibles in most cases). In as many as 30% of
the claims (30% IP, 15% OP, 5% PART B), the
reimbursement reported on the claims may be over
or under the actual Medicare payment amount.
REFER TO :
PMT_AMT_EXCEDG_CHRG_AMT_LIM
EDIT RULES :
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