TOTAL AMOUNT OF MONEY PAID BY MEDICAID FOR THIS SERVICE.
(DISPLAY SIGNED NUMERIC) (SAS USERS: ZONED DECIMAL - ZD8)
Comments
USER NOTES: THIS PAYMENT AMOUNT IS = $0 FOR ENCOUNTER RECORDS. IN MSIS, STATES ARE INSTRUCTED TO SET 'MEDICAID-AMOUNT-PAID' = $0 FOR RECORDS WITH 'TYPE-OF-CLAIM' = 3 (ENCOUNTERS). IN MAX, WE AGAIN SET 'MEDICAID PAYMENT AMOUNT' = $0 FOR ENCOUNTERS, TO ELIMINATE THE POSSIBILITY OF AMOUNTS > $0 APPEARING, IN ERROR. 'MEDICAID PAYMENT AMOUNT' IS SET VALUE = $0 BECAUSE MEDICAID PAYMENT FOR THESE ENCOUNTER RECORDS IS ALREADY CAPTURED IN PREMIUM PAYMENT RECORDS (WITH AMOUNTS > $0). THE PREMIUM PAYMENT RECORDS CONTAIN EITHER MSIS 'TYPE-OF-SERVICE' = 20 (CAPITATED PAYMENTS TO HMO, HIO, OR PACE PLANS), TOS = 21 (CAPITATED PAYMENTS TO PREPAID HEALTH PLANS - PHPs), TOS = 22 (CAPITATED PAYMENT FOR PRIMARY CARE CASE MANAGEMENT - PCCMs), OR TOS = 23 (CAPITATED PAYMENTS TO PRIVATE HEALTH INSURANCE - PHI). THERE ARE INSTANCES WHERE THIS PAYMENT AMOUNT MAY BE SET VALUE < $0 FOR FEE-FOR-SERVICE RECORDS. THIS SHOULD OCCUR ONLY ON CLINIC, PHYSICIAN OR OUTPATIENT DEPARTMENT BILLS FOR SELECTED STATES. THIS SITUATION HAS OCCURRED IN SEVERAL STATES, BUT HAS NOT BEEN A SIGNIFICANT ISSUE. WHERE THE 'MEDICAID PAYMENT AMOUNT' IS SET < $0 IN A MAX RECORD, THE PROVIDER BILLS USUALLY CONSIST OF A SUMMARY AND ONE OR MORE LINE ITEMS. THE SUMMARY CONTAINS INFORMATION ABOUT 'MEDICAID PAYMENT AMOUNT' AND OTHER PAYMENTS, E.G. PAYMENTS BY OTHER INSURERS, KNOWN AS THIRD PARTY LIABILITY (TPL). THE SUMMARY DOES NOT INCLUDE DETAIL ON THE ACTUAL SERVICES PROVIDED. THAT DETAIL IS FOUND IN THE LINE ITEMS, BUT THE LINE ITEMS DO NOT INCLUDE THE ACTUAL MEDICAID PAYMENT AMOUNT. FOR THESE REASONS, STATES ARE INSTRUCTED TO SUBMIT BOTH THE SUMMARY AND THE LINE ITEMS IN MSIS SO THAT WE WILL HAVE THE MOST COMPLETE RECORD POSSIBLE OF SERVICES AND PAYMENTS. FOR THE SAME REASON, BOTH TYPES OF RECORDS ARE ALSO CAPTURED IN MAX. THE INDIVIDUAL LINE ITEMS CONTAIN AN "ALLOWED PAYMENT AMOUNT", AN AMOUNT THAT HAS NOT BEEN REDUCED BY PAYMENTS FROM OTHER INSURERS (TPL) OR OUT-OF-POCKET PAYMENTS BY THE ELIGIBLE (PATIENT SHARE AMOUNTS). IF BOTH ALLOWED AND ACTUAL PAYMENTS ARE RETAINED, SUMS OF PAYMENT AMOUNTS ACROSS THE SUMMARY AND LINE ITEMS WILL OVERSTATE ACTUAL MEDICAID PAYMENTS. FURTHERMORE, THERE IS NO WAY TO APPORTION OR DISTRIBUTE THE ACTUAL MEDICAID PAYMENT AMOUNT FROM THE SUMMARY TO THE INDIVIDUAL LINE ITEMS. SO, THE DECISION WAS MADE TO RETAIN THE ALLOWED PAYMENT AMOUNTS IN THE LINE ITEMS, RETAIN THE TPL AMOUNT IN THE SUMMARY AND ADJUST MEDICAID PAYMENT (IN THE SUMMARY) SO THAT THE SUM ACROSS ALL RECORDS (SUMMARY AND LINE ITEMS) IS EQUAL TO THE ACTUAL MEDICAID PAYMENT AMOUNT. BECAUSE OF THIS, MEDICAID PAYMENT AMOUNT MAY BE ADJUSTED TO AN AMOUNT < $0 SO THAT THE SUM OF ALL PAYMENT AMOUNTS LESS TPL IS EQUAL TO THE ACTUAL MEDICAID PAYMENT AMOUNT.
NOTE: IN MAX 2008, A TYPOGRAPHICAL ERROR WAS CORRECTED -- TYPE OF SERVICE = 20 NOW INCLUDES PACE.
SOURCE: RECODED AS NOTED ABOVE USING MSIS CLAIMS FILE: 'MEDICAID-AMOUNT-PAID'.
USER NOTES: THIS PAYMENT AMOUNT IS = $0 FOR ENCOUNTER RECORDS. IN MSIS, STATES ARE INSTRUCTED TO SET 'MEDICAID-AMOUNT-PAID' = $0 FOR RECORDS WITH 'TYPE-OF-CLAIM' = 3 (ENCOUNTERS). IN MAX, WE AGAIN SET 'MEDICAID PAYMENT AMOUNT' = $0 FOR ENCOUNTERS, TO ELIMINATE THE POSSIBILITY OF AMOUNTS > $0 APPEARING, IN ERROR. 'MEDICAID PAYMENT AMOUNT' IS SET VALUE = $0 BECAUSE MEDICAID PAYMENT FOR THESE ENCOUNTER RECORDS IS ALREADY CAPTURED IN PREMIUM PAYMENT RECORDS (WITH AMOUNTS > $0). THE PREMIUM PAYMENT RECORDS CONTAIN EITHER MSIS 'TYPE-OF-SERVICE' = 20 (CAPITATED PAYMENTS TO HMO, HIO, OR PACE PLANS), TOS = 21 (CAPITATED PAYMENTS TO PREPAID HEALTH PLANS - PHPs), TOS = 22 (CAPITATED PAYMENT FOR PRIMARY CARE CASE MANAGEMENT - PCCMs), OR TOS = 23 (CAPITATED PAYMENTS TO PRIVATE HEALTH INSURANCE - PHI).
THERE ARE INSTANCES WHERE THIS PAYMENT AMOUNT MAY BE SET VALUE < $0 FOR FEE-FOR-SERVICE RECORDS. THIS SHOULD OCCUR ONLY ON CLINIC, PHYSICIAN OR OUTPATIENT DEPARTMENT BILLS FOR SELECTED STATES. THIS SITUATION HAS OCCURRED IN SEVERAL STATES, BUT HAS NOT BEEN A SIGNIFICANT ISSUE.
WHERE THE 'MEDICAID PAYMENT AMOUNT' IS SET < $0 IN A MAX RECORD, THE PROVIDER BILLS USUALLY CONSIST OF A SUMMARY AND ONE OR MORE LINE ITEMS. THE SUMMARY CONTAINS INFORMATION ABOUT 'MEDICAID PAYMENT AMOUNT' AND OTHER PAYMENTS, E.G. PAYMENTS BY OTHER INSURERS, KNOWN AS THIRD PARTY LIABILITY (TPL). THE SUMMARY DOES NOT INCLUDE DETAIL ON THE ACTUAL SERVICES PROVIDED. THAT DETAIL IS FOUND IN THE LINE ITEMS, BUT THE LINE ITEMS DO NOT INCLUDE THE ACTUAL MEDICAID PAYMENT AMOUNT. FOR THESE REASONS, STATES ARE INSTRUCTED TO SUBMIT BOTH THE SUMMARY AND THE LINE ITEMS IN MSIS SO THAT WE WILL HAVE THE MOST COMPLETE RECORD POSSIBLE OF SERVICES AND PAYMENTS. FOR THE SAME REASON, BOTH TYPES OF RECORDS ARE ALSO CAPTURED IN MAX.
THE INDIVIDUAL LINE ITEMS CONTAIN AN "ALLOWED PAYMENT AMOUNT", AN AMOUNT THAT HAS NOT BEEN REDUCED BY PAYMENTS FROM OTHER INSURERS (TPL) OR OUT-OF-POCKET PAYMENTS BY THE ELIGIBLE (PATIENT SHARE AMOUNTS). IF BOTH ALLOWED AND ACTUAL PAYMENTS ARE RETAINED, SUMS OF PAYMENT AMOUNTS ACROSS THE SUMMARY AND LINE ITEMS WILL OVERSTATE ACTUAL MEDICAID PAYMENTS. FURTHERMORE, THERE IS NO WAY TO APPORTION OR DISTRIBUTE THE ACTUAL MEDICAID PAYMENT AMOUNT FROM THE SUMMARY TO THE INDIVIDUAL LINE ITEMS. SO, THE DECISION WAS MADE TO RETAIN THE ALLOWED PAYMENT AMOUNTS IN THE LINE ITEMS, RETAIN THE TPL AMOUNT IN THE SUMMARY AND ADJUST MEDICAID PAYMENT (IN THE SUMMARY) SO THAT THE SUM ACROSS ALL RECORDS (SUMMARY AND LINE ITEMS) IS EQUAL TO THE ACTUAL MEDICAID PAYMENT AMOUNT. BECAUSE OF THIS, MEDICAID PAYMENT AMOUNT MAY BE ADJUSTED TO AN AMOUNT < $0 SO THAT THE SUM OF ALL PAYMENT AMOUNTS LESS TPL IS EQUAL TO THE ACTUAL MEDICAID PAYMENT AMOUNT.
NOTE: IN MAX 2008, A TYPOGRAPHICAL ERROR WAS CORRECTED -- TYPE OF SERVICE = 20 NOW INCLUDES PACE.
SOURCE: RECODED AS NOTED ABOVE USING MSIS CLAIMS FILE: 'MEDICAID-AMOUNT-PAID'.