HOSPITAL SERVICES Presented by Flora Coan Interim Administrator Professional Services Program Specialist - Hospital

APR-DRG (All Payer Refined Diagnosis Related Group) Implementation date: July 1, 2014 Grouper Version: Version 31 will be implemented on July 1, 2013 Relative Weights: The National Relative Weights will be applied. Hospital Base Rates: SFY 2011 base rates will be increased by 61.05%. Elimination of Low Volume/Unstable DRGs Transplant, Rehab, Psych and Transfer claims will continue to be paid under the current methodology. Outlier Threshold for all neonate and nervous system APR-DRGs at severity level 3 and severity level 4 will be the sum of the operating cost payment amount, the indirect medical education amount, and the capital-related cost payment amount, plus $30,000. The Outlier Threshold for all other APR-DRGs remains unchanged ($51,800).

APR-DRG (All Payer Refined Diagnosis Related Group) The National Relative Weights and the ALOS should be posted on DHHS website by July 1, 2014. The SFY15 Hospital Base Rates will reflect the 61.05% increase to the SFY11 base rates, plus the annual adjustment appropriated by the Nebraska Legislature. The SFY 15 Hospital Base Rates should be posted on DHHS website by 1, 2014.

Facility Based Physician Clinics Physician Clinic services provided in a hospital location or a facility under the hospital’s licensure are considered content of the physician service, not outpatient hospital services. Nebraska Medicaid does not recognize facility/hospital based non-emergency physician clinics for billing, reimbursement or cost reporting purposes except for itinerant physicians as defined in 471 NAC 18-004.41/10-005.21. Services and supplies incident to a physician’s professional service provided during a specific encounter are covered and reimbursed as physician clinic services if the service or supply is: Of the type commonly furnished in a physician’s office;

Facility Based Physician Clinics (continues) Furnished as an incidental, although integral, part of the physician professional services; and Furnished under the direct personal supervision of the physician The Physician’s clinic services must be billed on Form CMS-1500 or the standard electronic Health Care Claim: Professional transaction Revenue Code 51x

Misc: CLAIMS Submitting clean claims helps with reimbursement process Submit the correct bill type Submit Authorization number not case number Provide Admit date & time and Discharge date& time when two services were provided to the same client by the same provider Submit EOB from Medicare for dual eligible clients