The following words and terms, as used in this subchapter,
shall have the following meanings, unless the context clearly indicates
otherwise.
"Add-on amount" means an amount, calculated as a percentage
of the Statewide base rate, which is added to the Statewide base rate, and
which is determined on a hospital-specific basis using criteria established by
the Division that recognizes the additional costs associated with treating a
high volume of Medicaid and other low income patients.
"Delegated" means a Quality Improvement Organization's
process by which hospitals are authorized to have in-house medical staff
conduct utilization review. A delegated hospital would be subject to oversight
by the QIO for compliance and continued authority.
"Diagnosis Related Groups (DRGs)" means a patient
classification system in which cases are grouped by shared characteristics of
principal diagnosis, secondary diagnosis, procedures, age, sex and discharge
status.
"DRG weight" means the factor derived by measuring the
relative weight of the Statewide average cost of a specific DRG to the
Statewide average cost for all DRGs for the purpose of calculating the payment
for that specific DRG.
"Final rate" means a hospital's inpatient rate per case,
which includes the Statewide base rate and the hospital's add-on amounts, if
applicable, for a given rate year.
"Non-delegated" means the Quality Improvement Organization
retains responsibility to perform all of the utilization review activities in a
hospital.
"Quality Improvement Organization" or "QIO" means an
organization, which is composed of or governed by active physicians, and other
professionals where appropriate, who are representative of the active
physicians in the area in which the review mechanism operates and which is
organized in a manner that insures professional competence in the review of
services; formerly known as a peer review organization or a utilization review
organization.
"Rebasing" means setting the Statewide base rate using a more
current year's claim payment data.
"Recalibration" means the adjustment of all DRG weights to
reflect changes in relative resource use associated with all existing DRG
categories and/or the creation or elimination of DRG categories.
"Statewide base rate" means a rate per case, which applies to
all general acute care hospitals based on the total Medicaid inpatient
fee-for-service payment amount estimated for a given rate year.
"Utilization review" means:
1. A review of medical necessity and/or appropriateness
conducted during a patient's hospitalization, consisting of admission and
continued stay certification; or
2. A medical record review performed after a patient has been
discharged.
