OPPS definition
Examples of OPPS in a sentence
OPPS is a hospital outpatient prospective pay- ment system, based on nationally es- tablished APC payment amounts and standardized for geographic wage dif- ferences that includes operating and capital-related costs that are directly related and integral to performing a procedure or furnishing a service in a hospital outpatient department.
Blue Cross and Blue Shield of North Carolina will recognize and reimburse Level II HCPCS codes that have replaced Level I CPT codes by OPPS.
For acute care hospitals that qualify as a “Rural Provider” under the North Carolina State Health Plan Pricing Policy, outpatient services identified by CMS Outpatient Prospective Payment System (OPPS) Status codes will be priced based on 235% of the then current Medicare APC allowable rates, geographically adjusted.
Coding and fees determined under this schedule will be updated as CMS releases code updates, changes in the MFS relative values, including OPPS cap payments, or the CMS conversion factors.
Payment of services under the TRICARE OPPS is based on grouping outpatient procedures and services into ambulatory payment classification groups based on clinical and resource homogeneity, provider concentration, frequency of service and minimal op- portunities for upcoding and code frag- mentation.
For acute care hospitals that do not qualify as a “Rural Provider” under the North Carolina State Health Plan Pricing Policy, outpatient services identified by CMS Outpatient Prospective Payment System (OPPS) Status codes will be priced based on 225% of the then current Medicare APC allowable rates, geographically adjusted.
For other provider types, the Medicare allowable rate is based upon CMS Geographic Pricing Cost Indices (GPCI) and Resource Based Relative Value Scale (RBRVS) Relative Value Units (RVU) including Outpatient Prospective Payment System (OPPS) cap rates; the Clinical Laboratory Fee Schedule (CLAB); the Durable Medical Equipment, Prosthetics, Orthotics and Supplies Fee Schedule; including PEN (DMEPOS) and ‘Medicare Part B Drug Average Sales Price (ASP),’ as appropriate.
For acute care hospitals that do not qualify as a “Rural Provider” under the North Carolina State Health Plan Pricing Policy, outpatient services identified by CMS Outpatient Prospective Payment System (OPPS) Status codes will be priced based on for claims with admit/from dates on or before December 31, 2020, 230%, and for claims with admit/from dates on or after January 1, 2021, 200% of the then current Medicare APC allowable rates, geographically adjusted.
We may limit the number of accounts eligible for the Overdraft Privilege Program and *Service (OPPS) to one account per household.
Payment of services under the TRICARE OPPS is based on grouping outpatient procedures and services into ambulatory payment classification groups based on clinical and resource homogeneity, provider concentration, Amount in dispute.