Ill. Admin. Code tit. 89, § 148.403 - General Provisions - Inpatient
Effective for dates of service starting July 1, 2018, except when specifically designated otherwise in this Section:
a) General Provisions. Unless otherwise
indicated, the following apply to these Sections:
148.401
and
148.421.
1) Payments
A) Effective July 1, 2018, payments shall be
paid in 12 installments on or before the 7th State
business day of the month.
B) The
Department may adjust payments made under these Sections to comply with federal
law or regulations regarding disproportionate share, hospital-specific payment
limitations on government-owned or government-operated hospitals.
C) If the State or federal Centers for
Medicare and Medicaid Services finds that any federal upper payment limit
applicable to the payments under these Sections is exceeded, then the payments
under these Sections that exceed the applicable federal upper payment limit
shall be reduced uniformly to the extent necessary to comply with the federal
limit.
b)
Definitions. As used in this Section, unless the context requires otherwise:
1)
"General acute care admissions"
means, for a given hospital, the sum of inpatient hospital admissions provided
to recipients of medical assistance under Title XIX of the Social Security Act
for general acute care, excluding admissions for individuals eligible for
Medicare under Title XVIII of the Social Security Act (Medicaid/Medicare
crossover admissions), as tabulated from the Department's paid claims data for
general acute care admissions occurring during SFY 2015 as of October 28,
2016.
2)
"Occupancy ratio" is determined utilizing the Illinois Department of
Public Health Hospital Profile CY15 - Facility Utilization Data - Source 2015
Annual Hospital Questionnaire. Utilizes all beds and days including observation
days but excludes Long Term Care and Swing bed and their associated beds and
days.
3)
"Outpatient services" means, for a given hospital, the sum of the
number of outpatient encounters identified as unique services provided to
recipients of medical assistance under Title XIX of the Social Security Act for
general acute care, psychiatric care, and rehabilitation care, excluding
outpatient services for individuals eligible for Medicare under Title XVIII of
the Social Security Act (Medicaid/Medicare crossover services), as tabulated
from the Department's paid claims data for outpatient services occurring during
SFY 2015 as of October 28, 2016.
4)
"Total days" means, for a given
hospital, the sum of inpatient hospital days provided to recipients of medical
assistance under Title XIX of the Social Security Act for general acute care,
psychiatric care, and rehabilitation care, excluding days for individuals
eligible for Medicare under Title XVIII of the Social Security Act
(Medicaid/Medicare crossover days), as tabulated from the Department's paid
claims data for total days occurring during SFY 2015 as of October 28,
2016.
5)
"Total
admissions" means, for a given hospital, the sum of inpatient hospital
admissions provided to recipients of medical assistance under Title XIX of the
Social Security Act for general acute care, psychiatric care, and
rehabilitation care, excluding admissions for individuals eligible for Medicare
under Title XVIII of that Act (Medicaid/Medicare crossover admissions), as
tabulated from the Department's paid claims data for admissions occurring
during SFY 2015 as of October 28, 2016. [305 ILCS
5/5A-12.6(p)]
6) "Academic medical centers and major
teaching hospital" means the academic medical centers and major teaching
hospital definition found in Section
148.25.
7) "MIUR" means Medicaid inpatient
utilization rate for rate year 2017.
8) "Publicly owned hospital" means any
hospital owned by a political subdivision.
9) As used in this subsection, "service
credit factor" is determined based on a hospital's rate year 2017 Medicaid
inpatient utilization rate ("MIUR") rounded to the nearest whole
percentage.
c) Rate
reviews
1) A hospital shall be notified in
writing of the results of the payment determination pursuant to the applicable
Section.
2) Hospitals shall have a
right to appeal the calculation of, or their ineligibility for, payment if the
hospital believes that the Department has made a technical error. The appeal
must be submitted in writing to the Department and must be received or
postmarked within 30 days after the date of the Department's notice to the
hospital of its qualification for the payment amounts, or a letter of
notification that the hospital does not qualify for payments. Such a request
must include a clear explanation of the reason for the appeal and documentation
that supports the desired correction. The Department shall notify the hospital
of the results of the review within 30 days after receipt of the hospital's
request for review.
Notes
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