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  1. <?xml version="1.0" encoding="UTF-8" standalone="yes"?>
  2. <SoarianResponse>
  3. <ReimbursementUnit>
  4. <ServicePerformanceFromDate>1513789336548</ServicePerformanceFromDate>
  5. <ServicePerformanceThruDate>1514739736548</ServicePerformanceThruDate>
  6. <TotalChargeAmount>190721.55</TotalChargeAmount>
  7. <PrimaryAllocation>
  8. <nonCoveredDaysQuantity>0</nonCoveredDaysQuantity>
  9. <expectedAdjustedCoveredAmount>0</expectedAdjustedCoveredAmount>
  10. <expectedContractAmount>0</expectedContractAmount>
  11. <expectedContractualAllowanceAmount>0</expectedContractualAllowanceAmount>
  12. <expectedAdjustedNonCoveredAmount>0</expectedAdjustedNonCoveredAmount>
  13. <expectedNonCoveredChargeAmount>0</expectedNonCoveredChargeAmount>
  14. <ReimbursementTerm>
  15. <expectedReimbursementAmount>0</expectedReimbursementAmount>
  16. <expectedContractualAllowanceAmount>0</expectedContractualAllowanceAmount>
  17. <expectedNonCoveredChargeAmount>0</expectedNonCoveredChargeAmount>
  18. <expectedContractAmount>0</expectedContractAmount>
  19. <ServiceReimbursementTerm>
  20. <chargeRevenueCodeValue>120</chargeRevenueCodeValue>
  21. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  22. <itemNumber>1</itemNumber>
  23. <totalCharges>5188</totalCharges>
  24. <units>4.0</units>
  25. <chargeModifierValues></chargeModifierValues>
  26. <serviceFromDate>12/20/2017</serviceFromDate>
  27. </ServiceReimbursementTerm>
  28. <ServiceReimbursementTerm>
  29. <chargeRevenueCodeValue>120</chargeRevenueCodeValue>
  30. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  31. <itemNumber>1</itemNumber>
  32. <totalCharges>5188</totalCharges>
  33. <units>4.0</units>
  34. <chargeModifierValues></chargeModifierValues>
  35. <serviceFromDate>12/20/2017</serviceFromDate>
  36. </ServiceReimbursementTerm>
  37. <ServiceReimbursementTerm>
  38. <chargeRevenueCodeValue>120</chargeRevenueCodeValue>
  39. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  40. <itemNumber>1</itemNumber>
  41. <totalCharges>5188</totalCharges>
  42. <units>4.0</units>
  43. <chargeModifierValues></chargeModifierValues>
  44. <serviceFromDate>12/20/2017</serviceFromDate>
  45. </ServiceReimbursementTerm>
  46. <ServiceReimbursementTerm>
  47. <chargeRevenueCodeValue>120</chargeRevenueCodeValue>
  48. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  49. <itemNumber>1</itemNumber>
  50. <totalCharges>5188</totalCharges>
  51. <units>4.0</units>
  52. <chargeModifierValues></chargeModifierValues>
  53. <serviceFromDate>12/20/2017</serviceFromDate>
  54. </ServiceReimbursementTerm>
  55. <ServiceReimbursementTerm>
  56. <chargeRevenueCodeValue>200</chargeRevenueCodeValue>
  57. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  58. <itemNumber>2</itemNumber>
  59. <totalCharges>8610</totalCharges>
  60. <units>2.0</units>
  61. <chargeModifierValues></chargeModifierValues>
  62. <serviceFromDate>12/20/2017</serviceFromDate>
  63. </ServiceReimbursementTerm>
  64. <ServiceReimbursementTerm>
  65. <chargeRevenueCodeValue>200</chargeRevenueCodeValue>
  66. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  67. <itemNumber>2</itemNumber>
  68. <totalCharges>8610</totalCharges>
  69. <units>2.0</units>
  70. <chargeModifierValues></chargeModifierValues>
  71. <serviceFromDate>12/20/2017</serviceFromDate>
  72. </ServiceReimbursementTerm>
  73. <ServiceReimbursementTerm>
  74. <chargeRevenueCodeValue>206</chargeRevenueCodeValue>
  75. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  76. <itemNumber>3</itemNumber>
  77. <totalCharges>11226</totalCharges>
  78. <units>6.0</units>
  79. <chargeModifierValues></chargeModifierValues>
  80. <serviceFromDate>12/20/2017</serviceFromDate>
  81. </ServiceReimbursementTerm>
  82. <ServiceReimbursementTerm>
  83. <chargeRevenueCodeValue>206</chargeRevenueCodeValue>
  84. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  85. <itemNumber>3</itemNumber>
  86. <totalCharges>11226</totalCharges>
  87. <units>6.0</units>
  88. <chargeModifierValues></chargeModifierValues>
  89. <serviceFromDate>12/20/2017</serviceFromDate>
  90. </ServiceReimbursementTerm>
  91. <ServiceReimbursementTerm>
  92. <chargeRevenueCodeValue>206</chargeRevenueCodeValue>
  93. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  94. <itemNumber>3</itemNumber>
  95. <totalCharges>11226</totalCharges>
  96. <units>6.0</units>
  97. <chargeModifierValues></chargeModifierValues>
  98. <serviceFromDate>12/20/2017</serviceFromDate>
  99. </ServiceReimbursementTerm>
  100. <ServiceReimbursementTerm>
  101. <chargeRevenueCodeValue>206</chargeRevenueCodeValue>
  102. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  103. <itemNumber>3</itemNumber>
  104. <totalCharges>11226</totalCharges>
  105. <units>6.0</units>
  106. <chargeModifierValues></chargeModifierValues>
  107. <serviceFromDate>12/20/2017</serviceFromDate>
  108. </ServiceReimbursementTerm>
  109. <ServiceReimbursementTerm>
  110. <chargeRevenueCodeValue>206</chargeRevenueCodeValue>
  111. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  112. <itemNumber>3</itemNumber>
  113. <totalCharges>11226</totalCharges>
  114. <units>6.0</units>
  115. <chargeModifierValues></chargeModifierValues>
  116. <serviceFromDate>12/20/2017</serviceFromDate>
  117. </ServiceReimbursementTerm>
  118. <ServiceReimbursementTerm>
  119. <chargeRevenueCodeValue>206</chargeRevenueCodeValue>
  120. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  121. <itemNumber>3</itemNumber>
  122. <totalCharges>11226</totalCharges>
  123. <units>6.0</units>
  124. <chargeModifierValues></chargeModifierValues>
  125. <serviceFromDate>12/20/2017</serviceFromDate>
  126. </ServiceReimbursementTerm>
  127. <ServiceReimbursementTerm>
  128. <chargeRevenueCodeValue>250</chargeRevenueCodeValue>
  129. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  130. <itemNumber>4</itemNumber>
  131. <totalCharges>4149.08</totalCharges>
  132. <units>681.0</units>
  133. <chargeModifierValues></chargeModifierValues>
  134. <serviceFromDate>12/20/2017</serviceFromDate>
  135. </ServiceReimbursementTerm>
  136. <ServiceReimbursementTerm>
  137. <chargeRevenueCodeValue>258</chargeRevenueCodeValue>
  138. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  139. <itemNumber>5</itemNumber>
  140. <totalCharges>135.24</totalCharges>
  141. <units>2.0</units>
  142. <chargeModifierValues></chargeModifierValues>
  143. <serviceFromDate>12/20/2017</serviceFromDate>
  144. </ServiceReimbursementTerm>
  145. <ServiceReimbursementTerm>
  146. <chargeRevenueCodeValue>259</chargeRevenueCodeValue>
  147. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  148. <itemNumber>6</itemNumber>
  149. <totalCharges>1186.48</totalCharges>
  150. <units>122.0</units>
  151. <chargeModifierValues></chargeModifierValues>
  152. <serviceFromDate>12/20/2017</serviceFromDate>
  153. </ServiceReimbursementTerm>
  154. <ServiceReimbursementTerm>
  155. <chargeRevenueCodeValue>270</chargeRevenueCodeValue>
  156. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  157. <itemNumber>7</itemNumber>
  158. <totalCharges>721.25</totalCharges>
  159. <units>11.0</units>
  160. <chargeModifierValues></chargeModifierValues>
  161. <serviceFromDate>12/20/2017</serviceFromDate>
  162. </ServiceReimbursementTerm>
  163. <ServiceReimbursementTerm>
  164. <chargeRevenueCodeValue>272</chargeRevenueCodeValue>
  165. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  166. <itemNumber>8</itemNumber>
  167. <totalCharges>7673.25</totalCharges>
  168. <units>24.0</units>
  169. <chargeModifierValues></chargeModifierValues>
  170. <serviceFromDate>12/20/2017</serviceFromDate>
  171. </ServiceReimbursementTerm>
  172. <ServiceReimbursementTerm>
  173. <chargeRevenueCodeValue>278</chargeRevenueCodeValue>
  174. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  175. <itemNumber>9</itemNumber>
  176. <totalCharges>74486.25</totalCharges>
  177. <units>10.0</units>
  178. <chargeModifierValues></chargeModifierValues>
  179. <serviceFromDate>12/20/2017</serviceFromDate>
  180. </ServiceReimbursementTerm>
  181. <ServiceReimbursementTerm>
  182. <chargeRevenueCodeValue>300</chargeRevenueCodeValue>
  183. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  184. <itemNumber>10</itemNumber>
  185. <totalCharges>221.75</totalCharges>
  186. <units>4.0</units>
  187. <chargeModifierValues></chargeModifierValues>
  188. <serviceFromDate>12/20/2017</serviceFromDate>
  189. </ServiceReimbursementTerm>
  190. <ServiceReimbursementTerm>
  191. <chargeRevenueCodeValue>301</chargeRevenueCodeValue>
  192. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  193. <itemNumber>11</itemNumber>
  194. <totalCharges>3993.75</totalCharges>
  195. <units>56.0</units>
  196. <chargeModifierValues></chargeModifierValues>
  197. <serviceFromDate>12/20/2017</serviceFromDate>
  198. </ServiceReimbursementTerm>
  199. <ServiceReimbursementTerm>
  200. <chargeRevenueCodeValue>305</chargeRevenueCodeValue>
  201. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  202. <itemNumber>12</itemNumber>
  203. <totalCharges>1952</totalCharges>
  204. <units>32.0</units>
  205. <chargeModifierValues></chargeModifierValues>
  206. <serviceFromDate>12/20/2017</serviceFromDate>
  207. </ServiceReimbursementTerm>
  208. <ServiceReimbursementTerm>
  209. <chargeRevenueCodeValue>309</chargeRevenueCodeValue>
  210. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  211. <itemNumber>13</itemNumber>
  212. <totalCharges>155.5</totalCharges>
  213. <units>1.0</units>
  214. <chargeModifierValues></chargeModifierValues>
  215. <serviceFromDate>12/20/2017</serviceFromDate>
  216. </ServiceReimbursementTerm>
  217. <ServiceReimbursementTerm>
  218. <chargeRevenueCodeValue>320</chargeRevenueCodeValue>
  219. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  220. <itemNumber>14</itemNumber>
  221. <totalCharges>703.75</totalCharges>
  222. <units>3.0</units>
  223. <chargeModifierValues></chargeModifierValues>
  224. <serviceFromDate>12/20/2017</serviceFromDate>
  225. </ServiceReimbursementTerm>
  226. <ServiceReimbursementTerm>
  227. <chargeRevenueCodeValue>350</chargeRevenueCodeValue>
  228. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  229. <itemNumber>15</itemNumber>
  230. <totalCharges>2010.25</totalCharges>
  231. <units>1.0</units>
  232. <chargeModifierValues></chargeModifierValues>
  233. <serviceFromDate>12/20/2017</serviceFromDate>
  234. </ServiceReimbursementTerm>
  235. <ServiceReimbursementTerm>
  236. <chargeRevenueCodeValue>352</chargeRevenueCodeValue>
  237. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  238. <itemNumber>16</itemNumber>
  239. <totalCharges>1559.75</totalCharges>
  240. <units>1.0</units>
  241. <chargeModifierValues></chargeModifierValues>
  242. <serviceFromDate>12/20/2017</serviceFromDate>
  243. </ServiceReimbursementTerm>
  244. <ServiceReimbursementTerm>
  245. <chargeRevenueCodeValue>360</chargeRevenueCodeValue>
  246. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  247. <itemNumber>17</itemNumber>
  248. <totalCharges>10221</totalCharges>
  249. <units>1.0</units>
  250. <chargeModifierValues></chargeModifierValues>
  251. <serviceFromDate>12/20/2017</serviceFromDate>
  252. </ServiceReimbursementTerm>
  253. <ServiceReimbursementTerm>
  254. <chargeRevenueCodeValue>361</chargeRevenueCodeValue>
  255. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  256. <itemNumber>18</itemNumber>
  257. <totalCharges>2680.5</totalCharges>
  258. <units>1.0</units>
  259. <chargeModifierValues></chargeModifierValues>
  260. <serviceFromDate>12/20/2017</serviceFromDate>
  261. </ServiceReimbursementTerm>
  262. <ServiceReimbursementTerm>
  263. <chargeRevenueCodeValue>370</chargeRevenueCodeValue>
  264. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  265. <itemNumber>19</itemNumber>
  266. <totalCharges>3743</totalCharges>
  267. <units>19.0</units>
  268. <chargeModifierValues></chargeModifierValues>
  269. <serviceFromDate>12/20/2017</serviceFromDate>
  270. </ServiceReimbursementTerm>
  271. <ServiceReimbursementTerm>
  272. <chargeRevenueCodeValue>402</chargeRevenueCodeValue>
  273. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  274. <itemNumber>20</itemNumber>
  275. <totalCharges>313</totalCharges>
  276. <units>1.0</units>
  277. <chargeModifierValues></chargeModifierValues>
  278. <serviceFromDate>12/20/2017</serviceFromDate>
  279. </ServiceReimbursementTerm>
  280. <ServiceReimbursementTerm>
  281. <chargeRevenueCodeValue>420</chargeRevenueCodeValue>
  282. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  283. <itemNumber>21</itemNumber>
  284. <totalCharges>458</totalCharges>
  285. <units>4.0</units>
  286. <chargeModifierValues></chargeModifierValues>
  287. <serviceFromDate>12/20/2017</serviceFromDate>
  288. </ServiceReimbursementTerm>
  289. <ServiceReimbursementTerm>
  290. <chargeRevenueCodeValue>424</chargeRevenueCodeValue>
  291. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  292. <itemNumber>22</itemNumber>
  293. <totalCharges>487.5</totalCharges>
  294. <units>2.0</units>
  295. <chargeModifierValues></chargeModifierValues>
  296. <serviceFromDate>12/20/2017</serviceFromDate>
  297. </ServiceReimbursementTerm>
  298. <ServiceReimbursementTerm>
  299. <chargeRevenueCodeValue>430</chargeRevenueCodeValue>
  300. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  301. <itemNumber>23</itemNumber>
  302. <totalCharges>472.5</totalCharges>
  303. <units>5.0</units>
  304. <chargeModifierValues></chargeModifierValues>
  305. <serviceFromDate>12/20/2017</serviceFromDate>
  306. </ServiceReimbursementTerm>
  307. <ServiceReimbursementTerm>
  308. <chargeRevenueCodeValue>434</chargeRevenueCodeValue>
  309. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  310. <itemNumber>24</itemNumber>
  311. <totalCharges>362.5</totalCharges>
  312. <units>1.0</units>
  313. <chargeModifierValues></chargeModifierValues>
  314. <serviceFromDate>12/20/2017</serviceFromDate>
  315. </ServiceReimbursementTerm>
  316. <ServiceReimbursementTerm>
  317. <chargeRevenueCodeValue>460</chargeRevenueCodeValue>
  318. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  319. <itemNumber>25</itemNumber>
  320. <totalCharges>123.5</totalCharges>
  321. <units>2.0</units>
  322. <chargeModifierValues></chargeModifierValues>
  323. <serviceFromDate>12/20/2017</serviceFromDate>
  324. </ServiceReimbursementTerm>
  325. <ServiceReimbursementTerm>
  326. <chargeRevenueCodeValue>481</chargeRevenueCodeValue>
  327. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  328. <itemNumber>26</itemNumber>
  329. <totalCharges>40545</totalCharges>
  330. <units>2.0</units>
  331. <chargeModifierValues></chargeModifierValues>
  332. <serviceFromDate>12/20/2017</serviceFromDate>
  333. </ServiceReimbursementTerm>
  334. <ServiceReimbursementTerm>
  335. <chargeRevenueCodeValue>483</chargeRevenueCodeValue>
  336. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  337. <itemNumber>27</itemNumber>
  338. <totalCharges>4827.25</totalCharges>
  339. <units>3.0</units>
  340. <chargeModifierValues></chargeModifierValues>
  341. <serviceFromDate>12/20/2017</serviceFromDate>
  342. </ServiceReimbursementTerm>
  343. <ServiceReimbursementTerm>
  344. <chargeRevenueCodeValue>730</chargeRevenueCodeValue>
  345. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  346. <itemNumber>28</itemNumber>
  347. <totalCharges>531.75</totalCharges>
  348. <units>3.0</units>
  349. <chargeModifierValues></chargeModifierValues>
  350. <serviceFromDate>12/20/2017</serviceFromDate>
  351. </ServiceReimbursementTerm>
  352. <ServiceReimbursementTerm>
  353. <chargeRevenueCodeValue>732</chargeRevenueCodeValue>
  354. <chargeProcedureCodeValue></chargeProcedureCodeValue>
  355. <itemNumber>29</itemNumber>
  356. <totalCharges>1983.75</totalCharges>
  357. <units>5.0</units>
  358. <chargeModifierValues></chargeModifierValues>
  359. <serviceFromDate>12/20/2017</serviceFromDate>
  360. </ServiceReimbursementTerm>
  361. <ProcedureGroupResult/>
  362. <typeCode>0</typeCode>
  363. <contractTerm>
  364. <count>0</count>
  365. <lastChangedDate>0</lastChangedDate>
  366. <lastChangedTime>0</lastChangedTime>
  367. <id>3489594645</id>
  368. <contractTermName>DRG Pricer</contractTermName>
  369. <priority>100</priority>
  370. <rate>
  371. <ignore3MCoinsurance>false</ignore3MCoinsurance>
  372. <percentageValue>1.000000000</percentageValue>
  373. <rateType>DRG Pricer Rate</rateType>
  374. <separateBilateralProceduresIndicator>false</separateBilateralProceduresIndicator>
  375. </rate>
  376. <termQualification>
  377. <count>0</count>
  378. <lastChangedDate>0</lastChangedDate>
  379. <lastChangedTime>0</lastChangedTime>
  380. <displayName>All Charges</displayName>
  381. <displayableSourceExpression>TRUE</displayableSourceExpression>
  382. </termQualification>
  383. <contractPackage>
  384. <count>0</count>
  385. <lastChangedDate>0</lastChangedDate>
  386. <lastChangedTime>0</lastChangedTime>
  387. <id>3489594644</id>
  388. <packageQualificationId>0</packageQualificationId>
  389. <contractPeriodId>3489594642</contractPeriodId>
  390. <contractPackageName>Inpatient</contractPackageName>
  391. <priority>200</priority>
  392. <contractualAllowancePostingTimingCode>None</contractualAllowancePostingTimingCode>
  393. <contractualAllowancePostingTimingDaysValue>0</contractualAllowancePostingTimingDaysValue>
  394. <suppressDiscountIndicator>false</suppressDiscountIndicator>
  395. <excludeFromSurchargeCalculationIndicator>false</excludeFromSurchargeCalculationIndicator>
  396. <packageQualification>
  397. <count>0</count>
  398. <lastChangedDate>0</lastChangedDate>
  399. <lastChangedTime>0</lastChangedTime>
  400. <displayName>All Inpatient</displayName>
  401. <displayableSourceExpression>Encounter.typeCode EQ "IP"</displayableSourceExpression>
  402. </packageQualification>
  403. <ccmPriority>2</ccmPriority>
  404. </contractPackage>
  405. <contractPackageId>3489594644</contractPackageId>
  406. <ccmPriority>1</ccmPriority>
  407. <contractPeriodId>3489594642</contractPeriodId>
  408. </contractTerm>
  409. <explanation>DRG Pricer Rate could not be calculated. If the DRG is valid, then check DRG Provider values.</explanation>
  410. <explanationData>{"National FSP Amount":"0.00","Cost Outlier Pay":"0.00","Proc Used Count":"9","DRGGrouperVersion":"35.0","Dx Fn CCMC Usage":"0","Pass Thru Amt":"0.00","Mean Los 2":"7.2","DSH Payment":"0.00","Capital HSP":"0.00","Cap Pay":"0.00","Ind Teaching Pay":"0.00","LTACShortStayOutlierThresholdDate":null,"LTACBenefitExhaustDate":null,"Status":"92","Clinical Trial":"0.00","Hosp Re-Adm Reduct Pgm Adj":"0.00","Val Based Purchasing Pgm Adj":"0.00","TotalCoveredChargeAmount":190721.55,"ReplacedByStopLossIndicator":false,"Used Prin Dx POA":"Y","HAC Sts":"0","CalculatedPriority":"2.1","DRGGrouperMasterName":"Medicare","ICD Vers Used":"0 - ICD-10 codes used","Description":"Medicare","LengthOfStay":"12","Mean LOS":"5.0","Schedule Start Date":"10012017","Cost Outlier Chg Point":"0.00","Used Sec DX POA":"Y","Capital Old Hold Harmless":"0.00","Operating DSH Factor":"0.0000","Operating FSP":"0.00","Low Vol Adj Pct":"0.000000","DRG Grpr Used":"350","Proc HAC Usage":"0","RateType":"DRG Pricer Rate","Cost Weight":"7.7525","Schedule Stop Date":"01312018","Total Operating Amount":"0.00","Dx HAC Usage":"0","Return Cd":"00 - No errors, DRG assigned","Med Surg DRG Flag":"2 - Surgical DRG","LTACNonUtilizationStopDate":null,"Sec Dx Used Count":"23","New Tech Add-on Pay":"0.00","Operating Cost Outlier":"0.00","DRG PPS Rule Name Used":"Medicare Advantage | CMMC","Discharge Status Used":"01 - Home - Self-care (Routine)","Post Acute Care Transfer DRG":"1","305":"0.00","DRG":"266","Dx Affect DRG":"3","306":"0.00","307":"0.00","308":"0.00","309":"0.00","Operating IME Factor":"0.000000000","Cap DSH Pay":"0.00","Low Vol Addon Pay":"0.00","MDC":"5","Proc Oper Room Flag":"1","ServiceDate":"12/20/2017","310":"0.00","Err Rtn Cd Desc":"0.00","Grouper Version":"01220","Used Proc":"02RF38Z","Capital Exception":"0.00","Capital FSP":"0.00","LTACNonUtilizationStartDate":null,"Used Princ Dx":"I083","Overall Claim Edits":"0 - No errors","Orig Proc":"02RF38Z","Used Sec Dx":"I214","Dx HAC Cat":"00","INITIAL DRG":"266","Special Post Acute Care Transfer DRG":"1","Cap Cost Outlier Pay":"0.00","Used Admit Dx":"I214","Marginal Cost Factor":"0.8000","Proc Affect DRG":"3","Cap Ind Teaching Pay":"0.00","Device Amount":"0.00","Reimb Type":"1 - Medicare payment","Err Rtn Cd":"0.00","Operating IME":"0.00","SeverityOfIllnessCode":null,"Capital IME Fctr":"0.000000000","Status Description":"No Reimbursement Calculated, missing Clinical Trial number","Operating HSP":"0.00","LTACHighCostOutlierThresholdDate":null,"DRG Grpr Type":"1 - Medicare","Total DRG Payment":"0.00","Capital DSH Fctr":"0.0000","Pre/Post Pay Errs":"0 - MCE - no errors found","Operating DSH":"0.00","TotalDRGPaymentAmount":0.00,"Payment Without PassThru":"0.00","81":"1","82":"1","Device Credit Flag":"0"}</explanationData>
  411. <rateBasis>Per Case Per Case</rateBasis>
  412. <contractCalculationSuccessfulIndicator>false</contractCalculationSuccessfulIndicator>
  413. </ReimbursementTerm>
  414. <coveredDaysQuantity>12</coveredDaysQuantity>
  415. <totalCoveredChargeAmountForExclusions>0</totalCoveredChargeAmountForExclusions>
  416. </PrimaryAllocation>
  417. <TotalPayerExpectedReimbursementAmount>0</TotalPayerExpectedReimbursementAmount>
  418. <DRGValue>266</DRGValue>
  419. <ClaimNumber>6426366</ClaimNumber>
  420. <PayerContractName>UNITED HEALTHCARE MEDICARE | CMMC</PayerContractName>
  421. </ReimbursementUnit>
  422. <Errors>
  423. <errorCode>2000000021</errorCode>
  424. <message>DRG Pricer Rate could not be calculated. If the DRG is valid, then check DRG Provider values.</message>
  425. </Errors>
  426. </SoarianResponse>
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