MassHealth (Massachusetts Medicaid) is implementing EAPG pricing methodology for their acute outpatient claims and have a need to find a place on the 835 for outpatient institutional claims at the detail level for three fields that are critical for the provider to verify their payment.
The fields are:
1) The EAPG which is the grouping value for the service. Can 2110:REF (Service Identification) be used with REF01= ‘1S’ and REF02 with grouping value for the service?
2) The ‘adjusted weight’ which is used to calculate the payment.
Can 2110:QTY (Service Supplemental Quantity) be used with QTY01= ‘ZK’ and QTY02 with the adjusted weight used for payment calculation?
3) The Outlier amount which may be an addition to the payment.
Can 2110:AMT (Service Supplemental Amount) be used with AMT01= ‘ZK’ and AMT02 with the outlier amount that may be an addition to the payment?
Loop 2110 REF Service Identification segment with qualifier 1S Ambulatory Patient Group (AGP) Number can be used to report the EAPG since this is a version of an APG.
The ‘adjusted weight’ cannot be reported in the 5010 version of the 835. There is no element defined to report an adjusted weight.
The QTY Service Supplemental Quantity segment with qualifier ZK is defined for a federal Medicare or Medicaid payment mandate that required data to be reported. The implementation of a state pricing methodology, although critical for the provider to know, is not mandated.
The ‘outlier amount’ should be reported in a CAS segment with the appropriate CARC for cost outlier with a negative amount which adds money to the payment amount. Two CARCs that report a cost outlier are: 70 Cost outlier – Adjustment to compensate for additional costs. and A5 Medicare Claim PPS Capital Cost outlier Amount.
Please submit a request with detailed business requirements for the EAPG adjusted weight to modify a future version of the Health Care Claim Payment/Advice (835) Technical Report Type 3 (TR3) through the online TR3 Maintenance Request tool at: http://changerequest.x12.org/