Mont. Admin. r. 37.86.2905 - INPATIENT HOSPITAL SERVICES, GENERAL REIMBURSEMENT

(1) Prospective payment system (PPS) hospitals including in-state PPS facilities, distinct part units, border facilities, all out-of-state facilities, acute care psychiatric hospitals, and Center of Excellence facilities will be reimbursed under the All Patient Refined Diagnosis Related Groups (APR-DRG) prospective payment system described in ARM 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, and 37.86.2920.

(2) Interim reimbursement for cost-based facilities is based on a hospital-specific Medicaid inpatient cost-to-charge ratio, not to exceed 100%. For dates of service January 1, 2018 through June 30, 2018, the interim reimbursement is based on a hospital-specific Medicaid inpatient cost-to-charge ratio, less 2.99%, not to exceed 100%. Cost-based facilities will be reimbursed their allowable costs as determined according to ARM 37.86.2803. For cost report periods ending on or prior to December 31, 2017 final cost settlements for CAH facilities will be reimbursed at 101% of allowable costs. For cost report periods ending January 1, 2018 through June 30, 2018, final cost settlements for CAH facilities will be reimbursed at 97.98% of allowable costs. For cost report periods ending on or after July 1, 2018 final cost settlements for CAH facilities will be reimbursed at 101% of allowable costs.

(3) Except as otherwise specified in these rules, facilities reimbursed under the APR-DRG prospective payment system may be reimbursed for the following:

(a) cost outliers as set forth in ARM 37.86.2916;

(b) readmissions, partial eligibility, and transfers, as set forth in ARM 37.86.2918;

(c) hospital residents, as set forth in ARM 37.86.2920;

(d) disproportionate share hospital payments as provided in ARM 37.86.2925; and

(e) hospital reimbursement adjustor payments as provided in ARM 37.86.2928.

(4) PPS facilities may interim bill for stays equal to or exceeding 30 days at the same hospital.

(a) The interim rate will be a flat per diem rate times the number of covered days for the claim.

(b) Upon discharge the interim claims will be voided or credited by the hospital and the hospital must bill a single admit through discharge claim which will be paid by APR-DRG.

(c) The hospital must obtain authorization to interim bill prior to submission of the first claim and must provide medical records upon request of the department or the department's designated review organization for continued stay reviews.

(5) All PPS inpatient and outpatient hospital services that occur during an inpatient stay are included in the APR-DRG grouper except:

(a) dialysis services; and

(b) long-acting reversible contraceptives (LARCs) inserted at the time of delivery.

Notes

Mont. Admin. r. 37.86.2905

NEW, 1987 MAR p. 1658, Eff. 10/1/87; AMD, 1987 MAR p. 1804, Eff. 10/16/87; AMD, 1988 MAR p. 1199, Eff. 7/1/88; AMD, 1988 MAR p. 2570, Eff. 12/9/88; AMD, 1989 MAR p. 864, Eff. 6/30/89; AMD, 1989 MAR p. 1848, Eff. 11/10/89; AMD, 1990 MAR p. 1588, Eff. 8/17/90; AMD, 1991 MAR p. 310, Eff. 3/15/91; AMD, 1991 MAR p. 1025, Eff. 7/1/91; AMD, 1993 MAR p. 1520, Eff. 7/16/93; AMD, 1994 MAR p. 1732, Eff. 7/1/94; AMD, 1995 MAR p. 1162, Eff. 7/1/95; AMD, 1996 MAR p. 459, Eff. 2/9/96; AMD, 1996 MAR p. 1682, Eff. 6/21/96; AMD, 1997 MAR p. 1209, Eff. 7/8/97; AMD, 1998 MAR p. 2168, Eff. 8/14/98; AMD, 1999 MAR p. 1388, Eff. 6/18/99; AMD, 1999 MAR p. 2078, Eff. 9/24/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 1666, Eff. 6/30/00; AMD, 2000 MAR p. 2034, Eff. 7/28/00; EMERG; AMD, 2001 MAR p. 1119, Eff. 6/22/01; AMD, 2002 MAR p. 797, Eff. 3/15/02; EMERG; AMD, 2002 MAR p. 1991, Eff. 8/1/02; AMD, 2002 MAR p. 2665, Eff. 9/27/02; EMERG; AMD, 2003 MAR p. 999, Eff. 5/9/03; AMD, 2003 MAR p. 1652, Eff. 8/1/03; AMD, 2004 MAR p. 482, Eff. 2/27/04; AMD, 2005 MAR p. 265, Eff. 2/11/05; AMD, 2006 MAR p. 3078, Eff. 1/1/07; AMD, 2008 MAR p. 1983, Eff. 10/1/08; AMD, 2010 MAR p. 1534, Eff. 7/1/10; AMD, 2014 MAR p. 3096, Eff. 12/25/2014; AMD, 2017 MAR p. 2287, Eff. 12/9/2017; AMD, 2018 MAR p. 1734, Eff. 8/25/2018; AMD, 2018 MAR p. 2057, Eff. 10/20/2018

AUTH: 53-2-201, 53-6-113, MCA; IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA