Adjust rates for a CMS Outpatient calculation

Use these instructions to modify rates for a CMS Outpatient calc basis on a clause or term, as part of modeling post grouper custom pricing.

To set up post-grouper custom pricing on a contract:

1. Navigate to the desired clause or term for a provision with a clause or term with a CMS Outpatient calc basis.

2. In the Rates column, click Set.

   

3. In the Rates window, in the CMS Outpatient Adjustments View tab, select the type of adjustment:
   • No Adjustment – No adjustment is made to the rates coming from the grouping and pricing process. This is the default selection.
   • Overall Percentage – Adjust the post-grouping and pricing rate by a specified percentage.
   • APC Status indicator – Adjust the calc basis percentage based on the Status Indicator.
   • APC – Adjust the calc basis percentage based on the APC groupings.

   • Line Item Code – Adjust the calc basis percentage by specific line items on a claim.

     

4. Do one of the following, depending on your selection in the previous step:
   • If you selected Overall Percentage, then in the Adjustment field, enter a percentage written as a decimal value (e.g., 0.07), and then click Save. Skip to step 13.
   • If you selected APC Status Indicator, APC, or Line Item Code, proceed to step 5.
5. Click the CMS Outpatient Import Files tab.

6. In the Specified Files box, on the left of the header, from the drop-down, select the type of adjustment you selected in step 3, and then click Upload/Specify Files:

   

7. In the Upload/Specify Files dialog, click Choose File, and then select the file that fits the adjustment type you selected. In the following example, a file with SI adjustments is selected.

   

8. In the pane on the left, click the destination folder for the file, then in the Select a File to Upload pane, click Upload.

   After the file uploads, you should be able to see your file located in the destination folder:

   

9. Select the file on the left, and then on the right, in the Specify a file for Import section, click Specify.

10. If the file needs to be formatted before importing, you are prompted to make the selections in the dialog. Use the following example as a guide. When finished, click Save Specifications, and then close the dialog.

    

11. In the Specified Files section, click Attach.

    

12. Click the CMS Outpatient Adjustments View tab. The rates from the uploaded file display:

    

13. Close the Rates window. The Rates column on the clause/term now reads “View.”