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:
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. NCCI Edits (when present)
If a Procedure Code or combination of Procedure Codes violates NCCI edits, a $0 Expected reimbursement amount will display along with a yellow NCCI Edit badge. If a NCCI Edits are present but have been successfully overridden with the use of a modifier, a green NCCI Edit badge will display and an Expected will be shown. For more details on the NCCI Edits in the calculation, see the ‘NCCI Edits’ heading of the Detailed Explanation or the Help Article: Physician Services NCCI Edits.
F. 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
G. To clear a calculation, click the ‘Calculator’ breadcrumb
Click Calculator to clear the current calculation and begin a new one.
H. 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.
I. 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!