D.C. Mun. Regs. tit. 29, r. 29-4815

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-4815 - SPECIALTY INPATIENT SERVICES: PER DIEM REIMBURSEMENT (PD-APR-DRG)

4815.1

Reimbursement to the specialty hospitals reimbursed on a PD basis shall be calculated as set forth in this section.

4815.2

Payment based on the PD-APR-DRG method shall be determined as follows:

APR-DRG Relative Weight for Each CLAIM

X Final Base Rate

x

Number of Approved Days

+

Adjustments Based on Transfer Rule

4815.3

DHCF shall apply national hospital-specific relative value (HSRV) service weights, supplied by 3MT, for each APR-DRG. The case mix adjustment factor may be adjusted to account for any unexpected change in case mix related to improved coding practices.

4815.4

The hospital-specific PD base rate shall be based on costs from each specialty hospital's FY 2013 cost report standardized for variations in case mix, claims, and discharge data. The final PD base rate shall be determined by dividing the Medicaid inpatient operating costs by the Number of Medicaid Discharges in FY 2013.

4815.5

For each PD-APR-DRG specialty hospital claim that involves a transfer to another hospital or health care facility, DHCF shall pay the specialty hospital for the last day of the beneficiary's stay.

4815.6

For discharges occurring on or after October 1, 2014, psychiatric and pediatric hospitals not covered under Sections 4800 -4813 shall be paid transition rates. Following submission of the cost report, in accordance with Section 4822, DHCF shall determine allowable costs, notify the hospital of any over- or under-payments made during FY 2015, and establish a final rate for FY 2016.

D.C. Mun. Regs. tit. 29, r. 29-4815

Notice of Emergency and Proposed Rulemaking published at 57 DCR 2691 (March 26, 2010) [EXPIRED]; as amended by Notice of Emergency and Proposed Rulemaking published at 57 DCR 6837 (July 10, 2010) [EXPIRED]; as amended by Notice of Final Rulemaking published at 58 DCR 4323, 4334 (May 20, 2011); as amended by Final Rulemaking published at 59 DCR 15078 (December 28, 2012); amended by Final Rulemaking published at 63 DCR 5234 (4/8/2016)

Authority: The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program and for other purposes, approved December 27, 1967 (81 Stat. 774; D.C. Official Code § 1-307.02 (2001; Supp. 2008)) and section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2001; Supp. 2008)).