Illinois Administrative Code › Title 89 - SOCIAL SERVICES › Part 148 - HOSPITAL SERVICES › Subpart A - GENERAL PROVISIONS › Section 148.70 - Limitation On Hospital Services

Current through Register Vol. 48, No. 28, July 12, 2024
Effective for dates of discharge on or after July 1,
				  2014:
a) Payment for inpatient
				hospital care in general and specialty hospitals, including psychiatric
				hospitals, shall be made only when it is recommended by a qualified physician,
				and the care is essential as determined by the appropriate utilization review
				authority. For hospitals or distinct part units reimbursed on a per diem basis
				under Sections
				148.105
				through
				148.115
				and
				148.160
				through
				148.170,
				payment shall not exceed the number of days approved for the recipient's care
				by the appropriate utilization review authority (see Section
				148.240
				). If Medicare benefits are not paid because of non-approval by the utilization
				review authority, payment shall not be made on behalf of the
				Department.
b) For hospitals
				reimbursed on a per case basis, payment for inpatient hospital services shall
				be made in accordance with 89 Ill. Adm. Code 149.
c) For hospitals, or distinct part units
				reimbursed on a per diem basis, under Sections
				148.105
				through
				148.115
				and
				148.160
				through 148.170, payment for inpatient hospital services shall be made based on
				calendar days. The day of admission shall be counted. The day of discharge
				shall not be counted. An admission with discharge on the same day shall be
				counted as one day. If a recipient is admitted, discharged and re-admitted on
				the same day, only one day shall be counted.
d) Payment for inpatient psychiatric hospital
				care in a psychiatric hospital, as defined in Section
				148.25(d)(1),
				shall be made only when such services have been provided in accordance with
				federal regulations at 42 CFR 441, subparts C and D.
e) Payment for transplantation costs (with
				the exception of kidney and cornea transplants), including organ acquisition
				costs, shall be made only when provided by an approved transplantation center
				as described in Section
				148.82.
				Payment for kidney and cornea transplantation costs does not require enrollment
				as an approved transplantation center.
f) The Department shall reduce the payment
				for a claim that indicates the occurrence of a provider preventable condition
				during the admission as specified in this subsection (f).
1) The Department shall reduce each claim by
				the amount that the payment on the claim is increased directly due to the
				occurrence of and treatment for a healthcare acquired condition
				(HAC).
2) The Department shall not
				pay for services related to Other Provider Preventable Conditions
				(OPPCs).
3) For HACs, hospitals
				shall code inpatient claims with a Present on Admission (POA) indicator for
				principal and secondary diagnosis codes billed. For OPPCs, hospitals shall
				submit claims to report these incidents and will be instructed to populate the
				inpatient claims with specific supplementary diagnosis coding.
4) Definitions. As used in this subsection
				(f), the following terms are defined as follows:
"Provider Preventable Condition" means a health care acquired
				  condition as defined under the federal Medicaid regulation found at
				  42 CFR
				  447.26(2012) or an Other
				  Provider Preventable Condition.
"Other Provider Preventable Condition" means a wrong surgical
				  or other invasive procedure performed on a patient, a surgical or other
				  invasive procedure performed on the wrong body part, or a surgical procedure or
				  other invasive procedure performed on the wrong patient.