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Calculator Results Explained

The California Official Medical Fee Schedule (OMFS) Calculator instantly provides the correct reimbursement for a Bill based on Date of Service.

Here’s how it works:

A. Expected

B. Payment Amount

C. Balance Due

D. Expected %

E. Detailed Explanation

F. To clear a calculation, click the ‘Calculator’ breadcrumb

G. To print or save the current calculation, click ‘Download PDF’

H. To edit the current calculation, click ‘Edit’

A. Expected

The mandated reimbursement amount per California’s Official Medical Fee Schedule (OMFS). The Expected reimbursement amount is calculated using the fee schedules in effect for the entered Date of Service. The Expected reimbursement amount incorporates fee-affecting workers' comp billing ground rule calculations (eg., surgical cascading, MPPR, NCCI, MUE) and modifiers.  The Expected reimbursement amount does not calculate contracted or network discounts.

B. Payment Amount

The reimbursement amount paid by the claims administrator as reported on an Explanation of Review (EOR) and entered in the Payment Amount field on the previous screen. If not provided, this optional field defaults to $0. The Payment Amount is used to calculate the Expected %.

C. Balance Due

The Balance Due amount represents the Expected reimbursement amount minus the Payment Amount.

D. Expected %

Calculation of the Payment Amount divided by the Expected reimbursement amount. Viewing the Expected % helps quickly identify discounts being taken by the payer.

E. Detailed Explanation

Provides information about each Procedure Code in addition to information about the code’s relation to other Procedure Codes calculated with it.

Detailed Explanation includes:

  • OMFS Calculation Details
  • Billing Ground Rules
  • NCCI Edits
  • HCPCS Information

F. To clear a calculation, click the ‘Calculator’ breadcrumb

Click Calculator to clear the current calculation and begin a new one.

G. To print or save the current calculation, click ‘Download PDF’

Creates and opens a PDF of the current calculation and Detailed Explanation to be printed or saved.

H. To edit the current calculation, click ‘Edit’

Click Edit to make changes to the current calculation and update the Detailed Explanation.

Accurate calculations in seconds!

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