Effective for dates of discharge on or after July 1,
2014:
a) Payment for inpatient
hospital care in general and specialty hospitals, including psychiatric
hospitals, shall be made only when it is recommended by a qualified physician,
and the care is essential as determined by the appropriate utilization review
authority. For hospitals or distinct part units reimbursed on a per diem basis
under Sections
148.105
through
148.115
and
148.160
through
148.170,
payment shall not exceed the number of days approved for the recipient's care
by the appropriate utilization review authority (see Section
148.240
). If Medicare benefits are not paid because of non-approval by the utilization
review authority, payment shall not be made on behalf of the
Department.
b) For hospitals
reimbursed on a per case basis, payment for inpatient hospital services shall
be made in accordance with 89 Ill. Adm. Code
149.
c) For hospitals, or distinct part units
reimbursed on a per diem basis, under Sections
148.105
through
148.115
and
148.160
through 148.170, payment for inpatient hospital services shall be made based on
calendar days. The day of admission shall be counted. The day of discharge
shall not be counted. An admission with discharge on the same day shall be
counted as one day. If a recipient is admitted, discharged and re-admitted on
the same day, only one day shall be counted.
d) Payment for inpatient psychiatric hospital
care in a psychiatric hospital, as defined in Section
148.25(d)(1),
shall be made only when such services have been provided in accordance with
federal regulations at 42 CFR 441, subparts C and D.
e) Payment for transplantation costs (with
the exception of kidney and cornea transplants), including organ acquisition
costs, shall be made only when provided by an approved transplantation center
as described in Section
148.82.
Payment for kidney and cornea transplantation costs does not require enrollment
as an approved transplantation center.
f) The Department shall reduce the payment
for a claim that indicates the occurrence of a provider preventable condition
during the admission as specified in this subsection (f).
1) The Department shall reduce each claim by
the amount that the payment on the claim is increased directly due to the
occurrence of and treatment for a healthcare acquired condition
(HAC).
2) The Department shall not
pay for services related to Other Provider Preventable Conditions
(OPPCs).
3) For HACs, hospitals
shall code inpatient claims with a Present on Admission (POA) indicator for
principal and secondary diagnosis codes billed. For OPPCs, hospitals shall
submit claims to report these incidents and will be instructed to populate the
inpatient claims with specific supplementary diagnosis coding.
4) Definitions. As used in this subsection
(f), the following terms are defined as follows:
"Provider Preventable Condition" means a health care acquired
condition as defined under the federal Medicaid regulation found at
42 CFR
447.26(2012) or an Other
Provider Preventable Condition.
"Other Provider Preventable Condition" means a wrong surgical
or other invasive procedure performed on a patient, a surgical or other
invasive procedure performed on the wrong body part, or a surgical procedure or
other invasive procedure performed on the wrong patient.
h) Payment for caesarean sections
shall be at the normal vaginal delivery rate unless a caesarean section is
medically necessary.
