( 10 Valid for HD002 = Enhanced Ambulatory Patient 10 MassHealth Grouping (EAPG) (MassHealth) orgid ONLY ) Report the amount that the patient has incurred towards covered but over-utilized services. Scenario: Physical Therapy units that are authorized for 15 visits at $50 a visit Amount not but utilized 20. The amount reported covered at the Excluded here would be 25000 to state MC 11/8/12 Integer Currency claim line due to All 98% A2 Expenses by $250.00. Report 0 if benefit/plan there are no Excluded Expenses. Do limitation not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 Report the that defines the Lookup Indicator - Medicare element. EXAMPLE: 1 = Yes, MC 11/8/12 Table - int[1] Medicare All 100% A0 Indicator Medicare paid for part or all of Integer Payment Applied services. Value Description 1 Yes 2 No 3 Unknown 4 5 Not Applicable
10 Enhanced Ambulatory Patient Grouping (EAPG) (MassHealth) ( 10 Valid for HD002 = MassHealth orgid ONLY ) MC Excluded Expenses 11/8/12 Integer Currency Amount not covered at the claim line due to benefit/plan limitation Report the amount that the patient has incurred towards covered but over-utilized services. Scenario: Physical Therapy units that are authorized for 15 visits at $50 a visit but utilized 20. The amount reported here would be 25000 to state by $250.00. Report 0 if there are no Excluded Expenses. Do not code decimal or round up / down to whole dollars, code zero cents (00) when applicable. EXAMPLE: 150.00 is reported as 15000; 150.70 is reported as 15070 All 98% A2 MC Medicare Indicator 11/8/12 Lookup Table - Integer int[1] Indicator - Medicare Payment Applied Report the that defines the element. EXAMPLE: 1 = Yes, Medicare paid for part or all of services. All 100% A0 Value Description 1 Yes 2 No 3 Unknown 4 5 Not Applicable
v5-apcd-medical-claim-file-submission-guide-FINAL.docx