Medicare Claims Processing Manual (Pub. 100-04), Ch. 5 § 100.2
Obtaining Fee Schedule Amounts
100.2 - Obtaining Fee Schedule Amounts
(Rev. 1, 10-01-03)
The CMS furnishes A/B MACs (A) with an annual therapy abstract file and a CORF
supplemental file through the Medicare Telecommunications System. The CMS notifies
A/B MACs (A) when new files are available. A/B MACs (A) are responsible for
informing CORFs of new fee schedule amounts.
Payment is calculated at 80 percent of the allowed charge after deductible is met. The
allowed charge is the lower of billed charges or the fee schedule amount. Unmet
deductible is subtracted from the allowed charge, and payment is calculated at 80 percent
of the result.
EXAMPLE:
$120 Provider charge;
$100 MPFS amount.
Payment is 80 percent of the lower of the actual charge or fee schedule amount,
which in this case is $80.00. ($100.00 (MPFS) X 80 percent.)
The remaining 20 percent or $20 is the patient s coinsurance liability.
These codes are updated as needed by CMS.
If the A/B MAC (A) receives a claim for a Medicare covered CORF service with dates of
service on or after July 1, 2000, that does not appear on its fee schedule abstract file, it
has two options for obtaining pricing information:
1. It is provided with a therapy abstract file or CORF supplemental file that contains
all therapy services and their related prices. This supplemental file contains
approximately a million records, and may be used as a resource to extract pricing
data as needed. The data in the supplemental file is in the same format as the
MPFS abstract file in exhibit 1, but the fields defining the fee and outpatient
hospital indicators are not populated, instead they are space-filled.
2. It can contact the local A/B MAC (B) to obtain the price. When requesting the
pricing data, it advises the A/B MAC (B) to provide the nonfacility fee from the
MPFS. The MPFS supplemental file of physician fee schedule services is
available for retrieval through CMS’ Mainframe Telecommunications System.
The A/B MAC (A) is notified yearly of the file retrieval names and dates by a
program memorandum or other communication.