Decision Logic Used by the Pricer on Claims

130.2 Decision Logic Used by the Pricer on Claims (Rev. 4393, Issued: 09- 13-19: Effective: 11-25-19, Implementation: 11-25-19) The following components are used by the Hospice Pricer to determine the Hospice payment rate: • Wage Index • Labor and Non-Labor Amounts for each level of care rate - Routine Home Care (RHC) rates days 1 thru 60 - Routine Home Care (RHC) rates days 60+ - Continuous Home Care (CHC) rates - Inpatient Respite Care (IRC) rates - General Inpatient Care (GIP) rates • Service Intensity Add-on (SIA) rates These components are updated in the Hospice Pricer annually. Whenever the Hospice Pricer is updated, Medicare also publishes a Recurring Update Notification to inform providers and A/B MACs (HHH) about the changes. On each input record, Pricer performs the following calculations: 1. Determine the payment rate for the RHC level of care REV1 by multiplying the labor portion of the RHC payment rate by the associated BENE CBSA wage index and sum with the non-labor portion. The labor portion plus the non-labor portion, multiplied by the number of RHC days determines the payment amount. There are high/low RHC labor and non-labor share rates. The RHC low rate is applied to all RHC days for service beyond the 60th day (calculated by looking at the span between the ADMISSION DATE field and the LINE ITEM DOS1 date field plus NA DAY 1 ADD-ON UNITS). The RHC high rates are applied to service on the 60th day or earlier. If EOL Day 1 Add-on Units are present then SIA payment will be made. The payment will be equal to the CHC hourly rate, multiplied by the hours of nursing or social worker services provided (up to four hours total) that occurred on the day of service or a total of 16 units per day for the final seven days of life. 2. Determine the payment rate for the CHC level of care REV2 by multiplying the labor portion of the CHC payment rate by the associated BENE CBSA wage index and sum with the non-labor portion. The labor portion plus the non-labor portion, multiplied by the number of CHC hours (UNITS2 divided by 4) determines the payment amount. 3. Determine the payment rate for the IRC level of care REV3 by multiplying the labor portion of the IRC payment rate by the associated PROV CBSA wage index and sum with the non-labor portion. The labor portion plus the non-labor portion, multiplied by the number of IRC days determines the payment amount. 4. Determine the payment rate for the GIP level of care REV4 by multiplying the labor portion of the GIP payment rate by the associated PROV CBSA wage index and sum with the non-labor portion. The labor portion plus the non-labor portion, multiplied by the number of GIP days determines the payment amount. 5. Calculate the total claim payment by adding all the THEIR-PAY-CHRG fields plus the SIA payment amount total. This is informational only. The clams processing systems uses the THEIR-PAY- CHRG fields to make payment. Note: Pricer reduce payment by 2% if the hospice does not submit quality data. A value of 1 in the QIP REDUCTION IND field indicates that the hospice is subject to the 2% payment reduction due to not reporting required quality data.