Examples

EXAMPLE 1: LTR Days Cover Cost Outlier

Date of Service: 1/1 - 1/31 discharge 

Medically necessary days 30 

Covered charges $55,000 

Benefits available 30 LTR 

Covered days 30 

Noncovered days 0 

Cost report days 30 

All charges for Medicare approved revenue codes billed as covered No OC 47 needed

 Reimbursement: Full DRG plus cost outlier based on $55,000 covered charges

EXAMPLE 2: LTR Days Exhaust in the Cost Outlier 

Dates of service: 1/1 - 2/10 discharge 

Medically necessary days: 40 

Covered charges: $65,000 

Benefits available: 30 LTR 

Covered days: 30 

Noncovered days: 10 

Cost report days: 30

 30 days covered charges for Medicare approved revenue codes and 10 days noncovered charges. OC 47: 1/26 OC A3: 1/30 

Reimbursement: Full DRG plus cost outlier based on $55,000 covered charges ($50,000 inlier and $5,000 outlier

EXAMPLE 3: LTR Days Exhaust Prior to Cost Outlier 

Dates of service: 1/1 - 1/31 discharge 

Medically necessary days: 30 

Covered charges: $55,000 

Benefits available: 20 LTR 

Covered days: 20 

Noncovered days: 10 

Cost report days: 25 

25 days covered charges for Medicare approved revenue codes and 5 days noncovered charges OC 47: 1/26 OC A3 1/25 OSC 70: 1/21 -1/25

 Reimbursement: Full DRG payment, no cost outlier 

EXAMPLE 4: Coinsurance Days Exhaust Prior to Cost Outlier and No LTR Days Are Available

 Date of Service: 1/1 - 1/31 discharge Medically necessary days 30 

Covered charges $55,000

 Benefits available: 20 coinsurance 

Covered days: 20 

Noncovered days: 10

 Cost report days: 25 

25 days covered charges for Medicare approved revenue codes and 5 days noncovered charges OC 47: 1/26 OC A3: 1/25 OSC 70: 1/21 - 1/25 

Reimbursement: Full DRG payment, no cost outlier 

EXAMPLE 5: Coinsurance Days Exhaust Prior to Cost Outlier.

 LTR Days Exhausts in the Cost Outlier 

Date of Service: 1/1 - 2/10 discharge 

Medically necessary days 40 

Covered charges $65,000 Benefits available: 20 coinsurance and 10 LTR Covered days: 30 Noncovered days: 10 Cost report days: 35

 35 days covered charges for Medicare approved revenue codes and 5 days noncovered charges OC 47: 1/26

OC A3: 2/4 

OSC 70: 1/21 - 1/25

 Reimbursement: Full DRG payment, plus cost outlier based on $60,000 covered charges ($50,000 inlier, $10,000 outlier, $5,000 noncovered)

EXAMPLE 6: Full and Coinsurance Days Cover Cost Outlier

 Date of Service: 1/1 - 1/31 discharge Medically necessary days 30 

Covered charges $55,000 

Benefits available: 10 full and 20 coinsurance Covered days: 30

 Noncovered days: 0 

Cost report days: 30

 All charges for Medicare approved revenue codes billed as covered.

 OC 47: Not needed 

Reimbursement: Full DRG payment plus cost outlier based on $55,000 covered charges. 

EXAMPLE 7: Coinsurance Days and LTR Days Exhaust in the Cost Outlier 

Date of Service: 1/1 - 2/28 discharge

Medically necessary days 58 

Covered charges $83,000 

Benefits available: 10 full, 30 coinsurance and 10 LTR 

Covered days: 50 

Noncovered days: 8 Cost report days: 50 

50 days covered charges for Medicare approved revenue codes and 8 days noncovered charges 

OC 47: 1/26 OC A3: 2/19 

Reimbursement: Full DRG payment, plus cost outlier based on $75,000 covered charges ($50,000 inlier, $25,000 outlier, $8,000 noncovered)

EXAMPLE: 8: LTR Days Exhaust Prior to Cost Outlier and Noncovered Span(s)

 Present 

Dates of service: 1/1 - 1/31 discharge 

Medically necessary days: 28 OSC 76 1/10 - 1/11 

Covered charges: $55,000 

Benefits available: 20 LTR

 Covered days: 20

Noncovered days: 10 

Cost report days: 25 

25 days covered charges for Medicare approved revenue codes and 5 days noncovered charges 

OC 47: 1/28 OC A3 1/27 OSC 70: 1/23 -1/27 

Reimbursement: Full DRG payment, no cost outlier