Ariz. Admin. Code § 9-22-712.65

Current through Register Vol. 30, No. 50, December 13, 2024

Section R9-22-712.65 - DRG Provider Policy Adjustor

A. After calculating the DRG base payment as required in sections R9-22-712.62, R9-22-712.63, or R9-22-712.64, for claims from a high-utilization hospital, the product of the DRG base rate and the DRG relative weight for the post-HCAC DRG code shall be multiplied by a provider policy adjustor that is included in the AHCCCS capped fee schedule available on the agency's website.

B. A hospital is a high-utilization hospital if the hospital had:

1. Covered inpatient days subject to DRG reimbursement, determined using adjudicated claim and encounter data during the fiscal year beginning October 1, 2015, equal to at least four hundred percent of the statewide average number of AHCCCS-covered inpatient days at all hospitals;

2. A Medicaid inpatient utilization rate greater than 30% calculated as the ratio of AHCCCS-covered inpatient days to total inpatient days as reported in the hospital's Medicare Cost Report for the fiscal year ending 2016; and,

3. Received less than $2 million in add-on payment for outliers under R9-22-712.68, based on adjudicated claims and encounters for fiscal year beginning October 1, 2015.

Ariz. Admin. Code § R9-22-712.65

New Section made by final rulemaking at 20 A.A.R. 1956, effective 9/6/2014. Amended by final rulemaking at 23 A.A.R. 2896, effective 1/1/2018.