HOSPITAL SERVICES

1. HOSPITAL SERVICES Presented by Flora Coan Interim Administrator Professional Services Program Specialist - Hospital

2. APR-DRG (All Payer Refined Diagnosis Related Group) • Implementation date: July 1, 2014 • Grouper Version: Version 31 will be implemented on July 1, 2013 • Relative Weights: The National Relative Weights will be applied. • Hospital Base Rates: SFY 2011 base rates will be increased by 61.05%. • Elimination of Low Volume/Unstable DRGs • Transplant, Rehab, Psych and Transfer claims will continue to be paid under the current methodology. • Outlier Threshold for all neonate and nervous system APR-DRGs at severity level 3 and severity level 4 will be the sum of the operating cost payment amount, the indirect medical education amount, and the capital-related cost payment amount, plus $30,000. • The Outlier Threshold for all other APR-DRGs remains unchanged ($51,800).

3. APR-DRG (All Payer Refined Diagnosis Related Group) • The National Relative Weights and the ALOS should be posted on DHHS website by July 1, 2014. • The SFY15 Hospital Base Rates will reflect the 61.05% increase to the SFY11 base rates, plus the annual adjustment appropriated by the Nebraska Legislature. • The SFY 15 Hospital Base Rates should be posted on DHHS website by 1, 2014.

4. Facility Based Physician Clinics • Physician Clinic services provided in a hospital location or a facility under the hospital’s licensure are considered content of the physician service, not outpatient hospital services. • Nebraska Medicaid does not recognize facility/hospital based non-emergency physician clinics for billing, reimbursement or cost reporting purposes except for itinerant physicians as defined in 471 NAC 18-004.41/10-005.21. • Services and supplies incident to a physician’s professional service provided during a specific encounter are covered and reimbursed as physician clinic services if the service or supply is: • Of the type commonly furnished in a physician’s office;

5. Facility Based Physician Clinics (continues) • Furnished as an incidental, although integral, part of the physician professional services; and • Furnished under the direct personal supervision of the physician • The Physician’s clinic services must be billed on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction • Revenue Code 51x

6. Misc: CLAIMS • Submitting clean claims helps with reimbursement process • Submit the correct bill type • Submit Authorization number not case number • Provide Admit date & time and Discharge date& time when two services were provided to the same client by the same provider • Submit EOB from Medicare for dual eligible clients