Outpatient Pricer

50 - Outpatient Pricer (Rev. 1445, Issued: 02-08-08; Effective: 01-01-08; Implementation: 03-10-08) Outpatient Pricer determines the amount to pay as well as deductions for deductible and coinsurance. This CMS-developed software is updated on a quarterly basis to determine the APC line item price (as well as applicable coinsurance/deductible) based on data from the Outpatient Provider Specific File (OPSF), the beneficiary deductible record and the OCE output file. Pricer prepares an output data record with the following information: • All information passed from the OCE; • The APC line item payment amount; • The APC line item deductible; • The APC line item coinsurance amount; • The total cash deductible applied to the OPPS services on the claim; • The total blood deductible applied to the OPPS services on the claim; • The APC line item blood deductible; • The total outlier amount for the claim to be paid in addition to the line item APC payments. This amount is to be reported to CWF via value code 17 as is the process for inpatient outlier payments; and • A Pricer assigned review code to indicate why or how Pricer rejected or paid the claim. The Pricer implementation guide has information concerning Pricer processing reports, input parameters, and data requirements.