Common use of Dollar Amounts Clause in Contracts

Dollar Amounts. ‌ MassHealth wants to ensure that the dollar amounts on the individual lines of the claim represent the actual or computed amounts associated with each encounter. Therefore, whenever dollar amounts are not included at the detail level, and the summary-level line is not available, the MCE should add an extra detail line with a Record Indicator of 0 and report all summary-level amounts/quantities on that line. If the summary-level line is already available in the MCE’s source system and is not artificially created, then MassHealth would expect it to have a Record Indicator value of 4 (Per diem), 5 (DRG) or 6 (Bundled Summary-Level line when none of the other payment arrangements apply). All detail lines with zero-dollar amounts (that are not artificially created and are not summary-level lines) should have any value other than 0 or 6 placed in Record Indicator field. In such case, XXX decides on the value based on the definition of the Record Indicator in the table below. For the claims covered by sub-capitation payments, MCEs must report the amounts reported by the provider/vendor on their claims in the Net Payment field (#68) or the Fee-For-Service Equivalent (FFSE) and use Record Indicator value 2 to indicate the FFSE type of payment arrangement. See “Acronyms” section for MassHealth’s expectation for an FFSE. 0: Artificial Line Dollar amounts / quantities represent numbers that are available only at a summary level. 1: Fee-For-Service Dollar amounts should be available at the detail line level in the source system. 2: Encounter Record with Fee-For-Service- Equivalent (FFSE) Dollar amounts for a service paid under a capitation arrangement or otherwise not reflected in the source system. 3: Encounter Record w/out FFS equivalent DECOMMISSIONED 4: Per Diem Payment Use for Per Diem payment arrangements. One line would have the total dollar amount for the day or stay. 5: DRG Payment Use for DRG payment arrangements. One line would have the total dollar amount for the entire stay. 6: Bundled Summary-Level Line Total dollar amount for a bundled summary-level claim line where the dollar amounts represent numbers that are available only at a summary line level in the source system and is not artificially created. A record with indicator = 6 for a summary-level line of a bundled claim is used when none of the above payment arrangements apply. 7: Bundled detail line with 0 dollar amount A bundled detail claim line where the dollar amounts are 0 or not available at the detail level. A record with indicator = 7 is used for a detail-level line of a bundled claim when none of the above payment arrangements apply. Below are few examples of possible scenarios for Record Indictor values: 44444444444 1 4 - Per Diem Payment 0112 0 44444444444 2 4 - Per Diem Payment 0300 0 44444444444 3 4 - Per Diem Payment 0250 0 44444444444 4 4 - Per Diem Payment 0720 0 44444444444 5 0 - Artificial Line: dollar amounts available at summary level only NULL 10000 4444444444A 1 4 - Per Diem Payment 0410 0 4444444444A 2 4 - Per Diem Payment 0300 0 4444444444A 3 4 - Per Diem Payment 0250 0 4444444444A 4 4 - Per Diem Payment 0123 10000 55555555555 1 7 - Bundled detail line with 0 dollar amount 0 55555555555 2 7 - Bundled detail line with 0 dollar amount 0 55555555555 3 0 - Artificial Line: dollar amounts available at summary level only 100 00000000000 0 0 - Bundled detail line with 0 dollar amount 0 66666666666 2 7 - Bundled detail line with 0 dollar amount 0 66666666666 3 6 - Bundled Summary-Level Line 500 2.11 Claim Number & Suffix‌ Every Original / Void or Replacement claim submitted to MassHealth should have a new claim number + suffix combination. There can be no duplicate claim number + claim suffix in one feed

Dollar Amounts. ‌ MassHealth wants to ensure that the dollar amounts on the individual lines of the claim represent the actual or computed amounts associated with each encounter. Therefore, whenever dollar amounts are not included at the detail level, and the summary-level line is not available, the MCE should add an extra detail line with a Record Indicator of 0 and report all summary-level amounts/quantities on that line. If the summary-level line is already available in the MCE’s source system and is not artificially created, then MassHealth would expect it to have a Record Indicator value of 4 (Per diem), 5 (DRG) or 6 (Bundled Summary-Level line when none of the other payment arrangements apply). All detail lines with zero-dollar amounts (that are not artificially created and are not summary-level lines) should have any value other than 0 or 6 placed in Record Indicator field. In such case, XXX MCE decides on the value based on the definition of the Record Indicator in the table below. For the claims covered by sub-capitation payments, MCEs must report the amounts reported by the provider/vendor on their claims in the Net Payment field (#68) or the Fee-For-Service Equivalent (FFSE) and use Record Indicator value 2 to indicate the FFSE type of payment arrangement. See “Acronyms” section for MassHealth’s expectation for an FFSE. 0: Artificial Line Dollar amounts / quantities represent numbers that are available only at a summary level. 1: Fee-For-Service Dollar amounts should be available at the detail line level in the source system. 2: Encounter Record with Fee-For-Service- Equivalent (FFSE) Dollar amounts for a service paid under a capitation arrangement or otherwise not reflected in the source system. 3: Encounter Record w/out FFS equivalent DECOMMISSIONED 4: Per Diem Payment Use for Per Diem payment arrangements. One line would have the total dollar amount for the day or stay. 5: DRG Payment Use for DRG payment arrangements. One line would have the total dollar amount for the entire stay. 6: Bundled Summary-Level Line Total dollar amount for a bundled summary-level claim line where the dollar amounts represent numbers that are available only at a summary line level in the source system and is not artificially created. A record with indicator = 6 for a summary-level line of a bundled claim is used when none of the above payment arrangements apply. 7: Bundled detail line with 0 dollar amount A bundled detail claim line where the dollar amounts are 0 or not available at the detail level. A record with indicator = 7 is used for a detail-level line of a bundled claim when none of the above payment arrangements apply. Below are few examples of possible scenarios for Record Indictor values: 44444444444 1 4 - Per Diem Payment 0112 0 44444444444 2 4 - Per Diem Payment 0300 0 44444444444 3 4 - Per Diem Payment 0250 0 44444444444 4 4 - Per Diem Payment 0720 0 44444444444 5 0 - Artificial Line: dollar amounts available at summary level only NULL 10000 4444444444A 1 4 - Per Diem Payment 0410 0 4444444444A 2 4 - Per Diem Payment 0300 0 4444444444A 3 4 - Per Diem Payment 0250 0 4444444444A 4 4 - Per Diem Payment 0123 10000 55555555555 1 7 - Bundled detail line with 0 dollar amount 0 55555555555 2 7 - Bundled detail line with 0 dollar amount 0 55555555555 3 0 - Artificial Line: dollar amounts available at summary level only 100 00000000000 0 0 - Bundled detail line with 0 dollar amount 0 66666666666 2 7 - Bundled detail line with 0 dollar amount 0 66666666666 3 6 - Bundled Summary-Level Line 500 2.11 Claim Number & Suffix‌ Every Original / Void or Replacement claim submitted to MassHealth should have a new claim number + suffix combination. There can be no duplicate claim number + claim suffix in one feed