CMS Pub. 100-05, ch. 5, § 50.2.8.1

Outlier Amounts to All Service Lines with Potential Outlier Involvement

(Rev. 11550; Issued: 08-12-22; Effective: 10-13-22; Implementation:10-13-22)

MSPPAYOL (1) accepts OPPS and HHPPS MSP claims at the Ambulatory Payment

Classification (APC), Home Health Resource Groups (HHRG) and line levels, and (2) apportions

OPPS and HHPPS outlier amounts, when greater than zero, to all service lines that are PRICER-related and potential outlier service lines, that is, all service lines sent to the PRICER and returned

with a reimbursement. When MSP claims are received, A/B MAC (Part A) and A/B MAC (HHH)

must send the claim outlier amount received from the prospective payment PRICER systems to

the MSPPAY software. The shared system must set an indicator of "O" for any APC or HHRG

amount that includes a PRICER reimbursement. The indicator will enable MSPPAYOL to

determine which service amounts the outlier should apply. MSPPAYOL takes into consideration

the outlier amount, if available, and then apportion the outlier amount to the PRICER-related

service lines before calculating Medicare’s secondary payment. The subsequent service line level

calculation will account for the apportioned outlier amount resulting in a single payment amount

for each PRICER-related service line. MSPPAY will return the calculated MSP payment amounts

to the standard system along with an informational field reporting the apportioned outlier used to

calculate payment for that line item service or group of services. The modifications to

MSPPAYOL will allow for the service lines on the provider Remittance Advice (RA) to balance,

but the informational apportioned outlier amount will not be shown on the RA. The modifications

will also result in the line level MSP payment amounts being correctly reported on the PS&R

Report. If providers request Medicare adjust or reprocess HHPPS and OPPS MSP claims originally

processed prior to July 1, 2003, intermediaries must send these claims to MSPPAYOL.

A. MSPPAYPS

The CMS is making two modifications to MSPPAYPS as follows:

1 - MSPPAYPS is being modified to return provider and beneficiary line level

reimbursement amounts to the standard system.

2 - Although MSPPAYPS is no longer used to process OPPS and HHPPS MSP claims,

CMS will retain the sub-module for circumstances where Medicare is required to process MSP

claims under MSPPAYPS resulting from a court order, litigation or change to federal

regulations. The shared system retains a field where an indicator can be set that tells the standard

system to redirect these types of claims to MSPPAYPS instead of the MSPPAYOL sub-module.