US · guidance
CMS Pub. 100-04, ch. 3, § 150.17.1.2
Example 2: Coinsurance Days Greater Than or Equal to
Short Stay Outlier Threshold (30 day stay)
(Rev. 1, 10-01-03)
2a.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $55,000
Benefits available: 15 coinsurance and 60 LTR
Covered days: 20
Noncovered days: 10
Coinsurance days used: 15
LTR days used: 5
Cost report days: 30
OC 47: 1/26/03
OSC 70: 1/16/03 - 1/25/03
Reimbursement: Full DRG payment plus cost outlier based on $55,000 covered
charges
2b.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $53,000
Benefits available: 15 coinsurance and 3 LTR
Covered days: 18
Noncovered days: 12
Coinsurance days used: 15
LTR days used: 3
Cost report days: 28
OC 47: 1/26/03
OC A3: 1/28/03
OSC 70: 1/16/03 - 1/25/03
Reimbursement: Full DRG payment plus cost outlier based on $53,000 covered
charges
2c.
Date of service: 1/1/03 - 1/31/03
Medically necessary days: 30
Covered charges: $50,000
Benefits available: 15 coinsurance and 0 LTR
Covered days: 15
Noncovered days: 15
Coinsurance days used: 15
LTR days used:0
Cost report days: 25
OC 47: 1/26/03
OC A3: 1/25/03
OSC 70: 1/16/03 - 1/25/03
Reimbursement: Full DRG payment
History
(Rev. 1, 10-01-03)
Provenance
- Source
- cms.gov
- Retrieved
- 2026-08-25
- Edition
- iom-2026-08-25
- Content hash
d697db292a1e1783c4846b3f31ac7a4c0176827b16269d38af697738f5848430
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