Ariz. Admin. Code § 9-22-712.75

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

Section R9-22-712.75 - DRG Reimbursement: Payment for Administrative Days

A. Categories of Administrative Days. Administrative days fall into one of two categories, either (A)(1) or (A)(2).

1. Administrative days due to lack of appropriate placement options and not meeting inpatient medical criteria. Administrative days are days in which a member is admitted as an inpatient to an acute care hospital, does not meet the criteria for an acute inpa-tient stay, but is admitted or not discharged because;

(1) an appropriate placement outside the hospital is not available,

(2) the member cannot be safely discharged or transferred, or

(3) the Administration or the contractor failed to provide for the appropriate placement outside the hospital in a timely manner.

a. Administrative days may occur prior to an acute care episode, for example, when a woman with a high-risk pregnancy is admitted to a hospital while awaiting delivery.

b. Administrative days may also occur at the end of an acute care episode, for example, when a member is not discharged while awaiting placement in a nursing facility or other sub-acute or post-acute setting.

c. Administrative days may also include days in a receiving hospital when the member has been discharged from one acute care hospital for the purpose of receiving sub-acute services at the receiving hospital.

d. Administrative days do not include days when the member is awaiting appropriate placement or services that are currently available but the hospital has not transferred or discharged the member because of the hospital's administrative or operational delays.

e. Administrative days include inpatient claims covered by a RBHA or TRBHA that otherwise meet the criteria in subsection (A)(1). 2. Administrative days for claims with the principal diagnosis of behavioral health meeting inpatient medical criteria. Administrative days are days with dates of discharge on or after October 1, 2018, in which a member is admitted as an inpatient to an acute care hospital, meets the criteria for an acute inpatient stay, and the principal diagnosis on the hospital claim is a behavioral health diagnosis. Inpatient claims covered by a RBHA or TRBHA are not considered administrative days under subsection (A)(2) regardless of the principal diagnosis on the hospital claim.

B. Reimbursement of Administrative Days.

1. Administrative days under subsection (A)(1) are reimbursed at the rate the claim would have paid had the services not been provided in an inpatient hospital setting but had been provided at the appropriate level of care such as the rate paid for stays at a nursing facility.

2. Administrative days under subsection (A)(2) are reimbursed at the daily rate found on the Inpatient Behavioral Health Capped Fee-For-Service Schedule meeting the criteria of "Service Description - Psychiatric Stay," regardless of revenue code.

C. Prior authorization is required for administrative days.

D. A hospital shall submit a claim for administrative days separate from any claim for reimbursement for the inpatient stay otherwise reimbursable under the DRG payment methodology.

Ariz. Admin. Code § R9-22-712.75

New Section made by final rulemaking at 20 A.A.R. 1957, effective 9/6/2014. Amended by final rulemaking at 22 A.A.R. 2193, effective 10/1/2016. Amended by final rulemaking at 25 A.A.R. 3111, effective 10/1/2019.