Haw. Code R. § 17-1739-66 - Final prospective payment calculation

(a) Based on the prospective payment rates as adjusted in section 17-1739-65, and inflated in section 17-1739-68, a facility's payment for each inpatient stay in each classification shall be calculated as follows:

(1) For psychiatric discharges, multiply the per diem rate for a psychiatric discharge by the number of days of the psychiatric inpatient stay. The result shall be the payment for a psychiatric discharge;

(2) For nonpsychiatric service discharges in classification I facilities, multiply the per diem rate for the discharge by the number of days of the inpatient stay. The result shall be the payment for a nonpsychiatric service discharge;

(3) For surgical, maternity, and medical service discharges in classification II and III facilities, calculate the prospective payment for each facility as follows:

(A) Multiply the per diem rate component for the appropriate nonpsychiatric inpatient service category by the number of days of care for each service category for the inpatient discharge;

(B) Add the ancillary rate per discharge for the appropriate service category; and

(C) The result shall be the payment for each nonpsychiatric service discharge.

(4) If a woman delivers a child, then payment for the mother and baby shall be made separately. A per diem payment shall be made separately for care delivered to a normal newborn based on the costs and days associated with nursery care; and

(5) The following situations shall not be considered as constituting care that is delivered to a normal newborn, and shall be reimbursed as indicated:

(A) If it is medically necessary for the baby to remain in the hospital more than six days following birth (including the birthday), then the payment shall be determined separately based on the same criteria as any other discharge;

(B) If the claim form for services delivered to the newborn indicates an intensive care unit revenue code, then the payment for a medical case shall be made; or

(C) If both of the following requirements are met:

(i) The claim form reflects information that would result in the claim being characterized as a surgical case under section 17-1739-59(2); and

(ii) The newborn remains in the hospital for more than three days; then the payment for a surgical case shall be made.

(b) Payment shall be made under the prospective payment rate based on the date of discharge, except as provided in sections 17-1739-55(g) and 17-1739-71.

(c) Capital related costs shall be reimbursed as defined in section 17-1739-65(b).

Notes

Haw. Code R. § 17-1739-66

[Eff 11/13/95] (Auth: HRS § 346-59) (Imp: 42 C.F.R. §447.252)