S.D. Admin. R. 67:16:03:01

Current through Register Vol. 51, page 57, November 12, 2024

Section 67:16:03:01 - Definitions

Terms used in this chapter mean:

(1) "Benefit period," a period of days for which an individual may receive benefits for inpatient hospital services;

(2) "Case mix index," the sum of the DRG weight factors for all Medicaid discharges for a hospital during a specific time span divided by the number of discharges;

(3) "Cost outlier," a hospital claim with 70 percent of the billed charges exceeding the greater of 1.5 times the standard DRG payment amount or the outlier threshold available on the department's fee schedule website;

(4) "Diagnosis-related group," "DRG," a classification assigned to an inpatient hospital service claim based on the patient's age and sex, the principal and secondary diagnoses, the procedures performed, and the discharge status;

(5) "Emergency hospital care," the care necessary to prevent the death or serious impairment of the health of the recipient after the sudden onset of a medical condition that is manifested by symptoms of sufficient severity so as to be life-threatening or require immediate medical intervention;

(6) "Hospital services," items and services provided on the hospital's premises to a patient by a hospital under the direction of a physician or a dentist;

(7) "Inpatient," a patient who has been admitted to a hospital on the recommendation of a physician or a dentist;

(8) "Outpatient," a patient who receives professional services at a participating hospital, but is not provided with room, board, and services on a 24-hour basis;

(9) "Participating hospital," a hospital owned by the state in which it is located or licensed by the state licensing agency of the state in which it is located, certified by Medicare under Title XVIII of the Social Security Act, as amended to January 1, 2010, which agrees to participate under the medical assistance program; and

(10) "Target amount," a hospital's average Medicaid cost per discharge for routine services divided by its case mix index.

S.D. Admin. R. 67:16:03:01

SL 1975, ch 16; 42 SDR 51, effective 10/13/2015

General Authority: SDCL 28-6-1(1)(2)(3).

Law Implemented: SDCL 28-6-1(1)(2)(3), 28-6-1.1.