Mont. Admin. r. 37.86.2901 - INPATIENT HOSPITAL SERVICES, DEFINITIONS
(1) "Acute care psychiatric hospital" means a
psychiatric facility accredited by the Joint Commission on Accreditation of
Health Care Organizations that is devoted to the provision of inpatient
psychiatric care for persons under the age of 21 and licensed as a hospital by:
(a) the department; or
(b) an equivalent agency in the state in
which the facility is located.
(2) "Administratively necessary days" or
"inappropriate level of care services" means those services for which
alternative placement of a client is planned and/or effected and for which
there is no medical necessity for acute level inpatient hospital
care.
(3) "All patient refined
diagnosis related groups (APR-DRGs)" means DRGs that classify each inpatient
case based on claim information such as diagnosis, procedures performed, client
age, client sex, and discharge status.
(4) "Bad debt" means inpatient and outpatient
hospital services provided in which full payment is not received from the
client or from a third party payor, for which the provider expected payment and
the persons are unable or unwilling to pay their bill. Bad debts may be for
services provided to clients who have no health insurance or clients who are
underinsured and are net of payments (the amount that remains after payment)
made toward these services. For the purpose of uncompensated care, bad debt is
measured on the basis of revenue forgone, at full established rates, and bad
debt does not include either provider discounts or Medicare bad debt.
(5) "Base price" means a dollar amount,
including capital expenses, that is reviewed by the department each year to
allow for appropriation neutrality.
(6) "Border hospital" means a hospital
located outside Montana, but no more than 100 miles from the border.
(7) "Capital related cost" means a cost
incurred in the purchase of land, buildings, construction, and equipment as
provided in 42 CFR 413.130.
(8)
"Center of Excellence" means a hospital specifically designated by the
department as being able to provide a higher level multi-specialty of
comprehensive care and meets the criteria in ARM
37.86.2947(3).
(9) "Charity care" means inpatient and
outpatient hospital services in which hospital policies determine the client is
unable to pay and the hospital did not expect to receive full reimbursement.
Charity care results from a provider's policy to provide health care services
free of charge (or where only partial payment is expected) to individuals who
meet certain financial criteria. For the purpose of uncompensated care, charity
care is measured on the basis of revenue forgone, at full established rates.
Charity care does not include contractual write-offs.
(10) "Clinical trials" means trials that are
directly funded or supported by centers or cooperating groups funded by the
National Institutes of Health (NIH), Center for Disease Control (CDC), Agency
for Healthcare Research and Quality (AHRQ), Center for Medicare and Medicaid
Services (CMS), Department of Defense (DOD), or the Veterans Administration
(VA).
(11) "Cost-based hospital"
means a licensed acute care hospital that is reimbursed on the basis of
allowable costs.
(12) "Cost
outlier" means an additional payment for unusually high cost cases that exceeds
the cost outlier thresholds as set forth in ARM
37.86.2916.
(13) "Critical access hospital" means a
limited-service rural hospital licensed by the Montana Department of Public
Health and Human Services.
(14)
"Direct nursing care" means the care given directly to the client which
requires the skills and expertise of an RN or LPN.
(15) "Discharging hospital" means a hospital,
other than a transferring hospital, that formally discharges an inpatient.
Release of a client to another hospital, as described in (39) or a leave of
absence from the hospital will not be recognized as a discharge. A client who
dies in the hospital is considered a discharge.
(16) "Disproportionate share hospital" means
a hospital serving a disproportionate share of low income clients as defined in
section 1923 of the Social Security Act.
(17) "Disproportionate share hospital
specific uncompensated care" means the costs of inpatient and outpatient
hospital services provided to clients who have no health insurance or source of
third party coverage.
(18)
"Distinct part psychiatric unit" means a psychiatric unit of an acute care
general hospital that meets the requirements of 42 CFR part 412
(2008).
(19) "Distinct part
rehabilitation unit" means a rehabilitation unit of an acute care general
hospital that meets the requirements in 42 CFR 412.25 and 412.29.
(20) "Early elective delivery" means either a
nonmedically necessary labor induction or cesarean section that is performed
prior to 39 weeks and 0/7 days gestation.
(21) "Experimental/investigational service"
means a noncovered item or procedure considered experimental and/or
investigational by the U.S. Department of Health and Human Services or any
other appropriate federal agency.
(22) "Graduate medical education" (GME) means
a postgraduate primary care residency program approved by the Accreditation
Council for Graduate Medical Education (ACGME) offered by an eligible in-state
hospital for the purpose of providing formal hospital-based training and
education under the supervision of a licensed medical physician.
(23) "Hospital Acquired Condition (HAC)"
means a condition that occurs during an inpatient hospital stay and results in
a high cost or high volume of care or both; results in a claim being assigned
to a diagnosis related group (DRG) that has a higher payment when present as a
secondary diagnosis; and could have reasonably been prevented through the
application of evidence-based guidelines as defined in Section 5001(c) of the
Deficit Reduction Act of 2005.
(24)
"Hospital reimbursement adjustor (HRA)" means a payment to a Montana hospital
as specified in ARM
37.86.2928
and
37.86.2940.
(25) "Hospital resident" means a client who
is unable to be cared for in a setting other than the acute care hospital as
provided in ARM
37.86.2921.
(26) "Inpatient" means a person who has been
admitted to a hospital for bed occupancy for purposes of receiving inpatient
hospital services. A person generally is considered an inpatient if formally
admitted as an inpatient with an expectation that the client will remain more
than 24 hours. The physician or other practitioner is responsible for deciding
whether the client should be admitted as an inpatient. Inpatient hospital
admissions are subject to retrospective review by the department or the
department's designated review organization to determine whether the inpatient
admission was medically necessary for Medicaid payment purposes.
(27) "Inpatient hospital services" means
services that are ordinarily furnished in an acute care hospital for the care
and treatment of an inpatient under the direction of a physician, dentist, or
other practitioner as permitted by federal law, and that are furnished in an
institution that:
(a) is licensed or formally
approved as an acute care hospital by the officially designated authority in
the state where the institution is located;
(b) except as otherwise permitted by federal law, meets the
requirements for participation in Medicare as a hospital and has in effect a
utilization review plan that meets the requirements of 42 CFR 482.30;
or
(c) provides acute care
psychiatric hospital services as defined in this rule for individuals under age
21.
(28) "Inpatient
hospital utilization fee" means the utilization fee collected by the Department
of Revenue as provided in
15-66-102,
MCA.
(29) "Interim claim" in a
prospective payment system (PPS) hospital means a claim being billed for an
inpatient hospital stay equal to or exceeding 30 days at the same facility as
referenced in ARM
37.86.2905.
(30) "Long-acting reversible contraceptives
(LARCs)" means intrauterine devices and contraceptive implants that provide
long-acting reversible contraception.
(31) "Long term care hospital (LTCH)" means
an acute care hospital as defined in 42 CFR 412.
(32) "Low income utilization rate" means a
hospital's percentage rate as specified in ARM
37.86.2935.
(33) "Medicaid inpatient utilization rate"
means a hospital's percentage rate as specified in ARM
37.86.2932.
(34) "Out-of-state hospital" means a hospital
located more than 100 miles beyond the Montana state border.
(35) "Partial eligibility" means a client
that is only eligible for Medicaid benefits during a portion of the inpatient
hospital stay as specified in ARM
37.86.2918.
(36) "Present on Admission (POA)" means
conditions that are present at the time a medical order for an inpatient
admission occurs.
(37) "Prior
authorization (PA)" means the approval process required before certain services
are paid by Medicaid. Prior authorization must be obtained before providing the
service.
(38) "Prospective payment
system (PPS) hospital" means a hospital reimbursed pursuant to the diagnosis
related group (DRG) system. DRG hospitals are classified as such by the Centers
for Medicare and Medicaid Services (CMS) in accordance with 42 CFR part
412.
(39) "Relative weight" means a
weight assigned from a national database from 3M that reflects the typical
resources consumed per APR-DRG.
(40) "Routine disproportionate share
hospital" means a hospital in Montana which meets the criteria of ARM
37.86.2931.
(41) "Rural hospital" means for purposes of
determining disproportionate share hospital payments, an acute care hospital
that is located within a "rural area" as defined in 42 CFR
412.62(f)(iii).
(42) "Sole
community hospital" means a DRG reimbursed hospital classified as such by the
Centers for Medicare and Medicaid Services (CMS) in accordance with 42 CFR
412.92(a) through (d).
(43) "Third
party liability (TPL)" means any entity that is, or may be, liable to pay all
or part of the medical cost of care for a Medicaid eligible client.
(44) "Transferring hospital" means a hospital
that formally releases an inpatient client to another inpatient hospital or
inpatient unit of a hospital.
(45)
"Transplant" means to transfer either tissue or an organ from one body or body
part to another as referenced in ARM
37.86.4701.
A transplant may be either:
(a) "organ
transplantation", the implantation of a living, viable, and functioning human
organ for the purpose of maintaining all or a major part of that organ function
in the client; or
(b) "tissue
transplantation", the implantation of living, human tissue.
(46) "Uncompensated care" means hospital
services provided in which no payment is received from the client or from a
third party payor. Uncompensated care includes charity care and bad
debts.
(47) "Upper payment limit"
means a federal limit placed on fee-for-service reimbursement of Medicaid
providers.
(48) "Urban hospital"
means an acute care hospital that is located within a metropolitan statistical
area, as defined in 42 CFR 412.62(f)(2).
Notes
AUTH: 53-2-201, 53-6-113, MCA IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, 53-6-149, MCA
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