Get Changes To Cost Outlier Payment Calculation Pdf - Hfs - Hfs Illinois

This guide provides clear, step-by-step instructions on how to effectively complete the Changes To Cost Outlier Payment Calculation Pdf. Whether you are new to this process or need a refresher, this guide aims to support you in navigating the form with ease.

Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the Changes To Cost Outlier Payment Calculation Pdf and open it in your preferred online editor.
2. Begin by reviewing the document to familiarize yourself with its layout and components, ensuring you understand all sections that need to be filled out.
3. Locate the section that requires the DRG code from the claim. Enter the appropriate DRG code in the designated field as prompted by the form.
4. In the next section, input the total charges incurred for the service. Ensure that this figure accurately portrays the cost before any noncovered charges are deducted.
5. Next, identify any noncovered charges associated with the claim and enter this amount in the specified field.
6. Calculate the net charges by subtracting the noncovered charges from the total charges. Record the net charges in the designated area.
7. Refer to the provided tables in the handbooks or appendices for the IME factor and other relevant ratios. Fill in the required information as per your specific claim.
8. Continue through the form, carefully following instructions to compute the gross outlier cost and adjustments based on the formulas provided within the document.
9. Once all fields have been completed and reviewed, save your changes in the online editor.
10. Choose an option to download, print, or share the completed form as required, ensuring that you maintain a copy for your records.

Complete your documentation online to facilitate a smooth submission process.