405 IAC 1-8-3 - Reimbursement methodology
Current through March 30, 2022
Authority: IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15-15-1
Sec. 3.
(a) The
reimbursement methodology for all covered outpatient hospital and ambulatory
surgical center services shall be subject to the lower of the submitted charges
for the procedure or the established fee schedule allowance for the procedure
as provided in this section. Services shall be billed in accordance with
provider manuals and update bulletins.
(b) Surgical procedures shall be:
(1) classified into a group corresponding to
the Medicare ambulatory surgical center (ASC) methodology; and
(2) paid a rate established for each ASC
payment group.
Outpatient surgeries that are not classified into the nine (9) groups designated by Medicare will be classified by the office into one (1) of those nine (9) groups or additional payment groups. Reimbursement will be based on the Indiana Medicaid statewide allowed amount for that service in effect during state fiscal year 2003.
(c) Payments for emergent care that:
(1) do not include surgery; and
(2) are provided in an emergency department,
treatment room, observation room, or clinic; will be based on the statewide fee
schedule amount in effect during state fiscal year 2003.
(d) Payments for nonemergent care that:
(1) do not include surgery; and
(2) are provided in an emergency department,
treatment room, observation room, or clinic; will be based on the statewide fee
schedule amount in effect during state fiscal year 2003.
(e) Reimbursement for laboratory procedures
is based on the Medicare fee schedule amounts.
(f) Reimbursement for the technical component
of radiology procedures shall be based on the Medicaid physician fee schedule
rates for the radiology services technical component.
(g) Reimbursement allowances for all
outpatient hospital procedures not addressed elsewhere in this section, for
example, therapies, testing, etc., shall be equal to the Medicaid statewide fee
schedule amounts in effect during state fiscal year 2003.
(h) Payments will not be made for outpatient
hospital and ambulatory surgical center services occurring within three (3)
calendar days preceding an inpatient admission for the same or related
diagnosis. The office may exclude certain services or categories of service
from this requirement. Such exclusions will be described in provider manuals
and update bulletins.
(i) The
established rates for hospital outpatient and ambulatory surgical center
reimbursement shall be reviewed annually by the office and adjusted, as
necessary, in accordance with this section.
(j) The state shall not pay for
provider-preventable conditions, as defined at 42 CFR 447.26(b).
(k) Notwithstanding all other provisions of
this rule, reimbursement rates shall be reduced, through June 30, 2021, by
three percent (3%) for outpatient hospital services (excluding ambulatory
surgical center reimbursement) that have been calculated under this
rule.
Notes
The following state regulations pages link to this page.
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.