CSP claims for primary PPS payers

Path: Claims > Process > Process a Cycle

When the patient's primary insurance is PPS, any regular or hybrid insurance can be designated as the CSP payer, the only exceptions being New York Medicaid insurances with the "N" billing method.

CSP claims are generated for any standard and specialized formats.

When a regular or hybrid payer is selected as CSP for primary PPS insurance, the application generates primary PPS claims as usual.

• Once the final PPS claim is closed and the balance of both RAP and final claims is zero, the system generates a CSP claim with the same date range as that of the final PPS claim.
• Usually, the CSP claim has a sixty-day date range (a full PPS episode).
• Changes to the CSP claim date range follow the PPS claim range, for example, the episode may finish earlier if a patient is discharged in the middle of the episode.
• If the CSP insurance has some rules for claim splitting (by authorizations, branch, and so on), they are ignored as the CSP claim range is based on the primary claim range.
• The exception may be a situation when the CSP payer has expired.

The expected CSP amount is calculated based on the amounts of the PPS primary episode.

• The system does not automatically pull the PPS EEP amount on paper claims for CSP.
• To see the PPS EEP amount when the form is printed (for example in FL 39-41 of the UB-04 billing form), use the patient level claim constants for value codes entry.

The formula for calculating the CSP claims gross and net amounts is the following:

• Net of the RAP claim + Net of the Final claim - (system generated adjustments) - prior payments

As the CSP claims for primary PPS payers take into consideration the EEP amount from the primary PPS claims, the gross, standard net, and actual net amounts of the CSP claims are calculated based on the net amount of the primary payer's PPS claim and prior payments regardless of the billing method. Thus, the billing method for CSP (A or B) is used only for the claim printing: the rates for the services are pulled from a primary payer if a billing method is B; otherwise, the CSP payer's own rates are printed for service lines.

When a PPS payer is selected as CSP for the primary PPS insurance, the system does not generate PPS CSP claims.