Claim
ADEBIYI, FOLAYEMI
MR#: 90010171
04/10/25 - 06/08/25
Episode: 1 (Billable)
DIGNITY HEALTH/DIGNITY COMMUNITY CARE HOSPITAL (LOA)
Private Pay
04/10/25-06/08/25
60-Day Billing Period
ICD-CM
OASIS
Functional Level Points:
HIPPS Reported

Timing / Source

Clinical Grouping

Functional Level

Comorbidity
1
Placeholder
Casemix-Weight
LUPA Threshold
Projected Visits
Skilled Nursing 1
Start Date End Date Frequency Projected Visit(s) Confirmed Visit(s)
04/10/25 04/11/25 1/WK X 1WKS
1
1
04/12/25 04/18/25 2/WK X 1WKS
2
04/19/25 04/25/25 1/WK X 1WKS
1
Physical Therapy 1
Start Date End Date Frequency Projected Visit(s) Confirmed Visit(s)
05/26/25 05/30/25 1/WK X 1WKS
1
1
5
2
Reimbursement
Visit Cost for 30-Day Period
LUPA Threshold
Total Visits
Claim Type
Low Utilization Payment Adjustment (LUPA) v2
Full Episode Payment (FEP)
2057.35
National Standardized 30-Day Period Payment Rate
x
...
Case-Mix Adjustment for HIPPS
=
Case-Mix Adjusted Period Payment Amount
Case-Mix Adjusted Period Payment Amount
x
0.761
=
Labor Portion of the Case-Mix Adjusted Period Payment Amount
Case-Mix Adjusted Period Payment Amount
x
0.239
=
Non-Labor Portion of the Case-Mix Adjusted Period Payment Amount
1.1083
Wage Index Value
x
Labor Portion of the Case-Mix Adjusted Period Payment Amount
=
Wage-Adjusted Labor Portion of the Case-Mix Adjusted Period Payment Amount
Non-Labor Portion of the Case-Mix Adjusted Period Payment Amount
+
Wage-Adjusted Labor Portion of the Case-Mix Adjusted Period Payment Amount
=
Total Case-Mix and Wage-Adjusted Period Payment Amount
Outlier Check
Total Wage-Adjusted Fixed Dollar Loss Amount
2057.35
National Standardized 30-Day Period Payment Rate
x
0.71
Fixed Dollar Loss Ratio
=
...
Fixed Dollar Loss Amount
...
Fixed Dollar Loss Amount
x
0.761
=
...
Labor Portion of the Fixed Dollar Loss Amount
...
Fixed Dollar Loss Amount
x
0.239
=
...
Non-Labor Portion of the Fixed Dollar Loss Amount
...
Labor Portion of the Fixed Dollar Loss Amount
x
1.1083
Wage Index Value
=
...
Wage-Adjusted Amount of the Fixed Dollar Amount
...
Wage-Adjusted Amount of the Fixed Dollar Amount
+
...
Non-Labor Portion of the Fixed Dollar Loss Amount
=
...
Total Wage-Adjusted Fixed Dollar Loss Amount
Total Wage-Adjusted Imputed Cost Amount
...
Total Unit Cost
x
0.761
=
Labor Portion of the Imputed Costs of All Disciplines
...
Total Unit Cost
x
0.239
=
Non-Labor Portion of the Imputed Cost Amount of All Disciplines
Labor Portion of the Imputed Costs of All Disciplines
x
1.1083
Wage Index Value
=
Wage-Adjusted Labor Portion of the Imputed Cost Amount for All Disciplines
Wage-Adjusted Labor Portion of the Imputed Cost Amount for All Disciplines
x
Non-Labor Portion of the Imputed Cost Amount of All Disciplines
=
...
Total Wage-Adjusted Imputed Cost Amount
Outlier Threshold Amount
...
Total Wage-Adjusted Fixed Dollar Loss Amount
+
Total Case-Mix and Wage-Adjusted Period Payment Amount
=
Outlier Threshold Amount
...
Total Wage-Adjusted Imputed Cost Amount
-
Outlier Threshold Amount
=
Total Wage-Adjusted Imputed Cost - Outlier Threshold Amount
Total Wage-Adjusted Imputed Cost - Outlier Threshold Amount
x
0.8
Loss-Sharing Ratio
=
Outlier Payment
Reimbursement
Total Case-Mix and Wage-Adjusted Period Payment Amount
+
Outlier Payment
=
Total Payment for 30-Day Period
Total Payment for 30-Day Period
-
2% Sequastration
=
Reimbursement
* This excludes Medical Supply Cost
Profit/Loss
Reimbursement
-
Visit Cost
=
Created Date: 04/10/2025




This is due for No-Pay RAP. Please notify Noreen.