Florida Administrative Code › 59 - AGENCY FOR HEALTH CARE ADMINISTRATION › 59G - Medicaid › Chapter 59G-6 - REIMBURSEMENT TO PROVIDERS › Section 59G-6.031 - Enhanced Ambulatory Patient Grouping Reimbursement Methodology for Hospital Outpatient Services and Ambulatory Surgical Centers

Current through Reg. 50, No. 138; July 16, 2024
(1) This rule applies to all hospitals and
				ambulatory surgical centers (ASC) rendering Florida Medicaid outpatient
				hospital services to recipients, in accordance with rules
				59G-4.160 and
				59G-4.020, Florida
				Administrative Code, (F.A.C.), respectively.
(2) Definitions.
(a) Annual Appropriation - The funding
				provided in the General Appropriations Act and the incorporated Medicaid
				Hospital Funding Programs document.
(b) Automatic Rate Enhancement - An
				additional fee applied to each payable claim line.
(c) Base Rate - An amount calculated using 12
				months of historical claims data.
(d) Base Year - A period of historical claims
				extracted for a pricing simulation.
(e) Bundled EAPG Payment - A single payment
				applied to one claim line that includes reimbursement for services reported on
				multiple claim lines.
(f) Charge
				Cap - A limitation that ensures the Medicaid-allowed amount does not exceed the
				submitted charges on either individual service line(s), or overall for the
				entire outpatient claim.
(g)
				Crossover Claim - Provider claim for services provided to recipients who are
				eligible for Medicare and Medicaid services, or who have other third-party
				insurance.
(h) Discounting Claim
				Line - A service line on a claim where the payment is adjusted.
(i) Enhanced Ambulatory Patient Groups (EAPG)
				- A product of 3M Health Information Systems (HIS) that categorizes outpatient
				services and procedures into groups for payment based on clinical information
				present on an outpatient claim.
(j)
				EAPG Code - Proprietary number developed by 3M HIS to indicate a specific
				grouping of services.
(k) EAPG
				Methodology - Reimbursement system that provides an all-inclusive rate for all
				services and items furnished during an outpatient visit, unless otherwise
				specified. The methodology categorizes the amount and type of services provided
				during an outpatient visit and groups together procedures, medications,
				materials, and patient factors that share similar characteristics and resource
				utilization. Each category is assigned an EAPG code. Each EAPG code is assigned
				a relative weight (which may equal zero) that is used to calculate
				payment.
(l) Florida Medicaid
				Outpatient Charges - The billed charges for outpatient services covered by the
				Florida Medicaid program for a hospital or an ASC.
(m) General Hospital - As defined in section
				395.002(10),
				Florida Statutes (F.S.).
(n) High
				Medicaid Outpatient Utilization Hospital - A hospital that renders 55 percent
				or more of its total annual outpatient services to Florida Medicaid
				recipients.
(o) Payment Adjustment
				Factor - A multiplier used to package and consolidate payment for similar
				services; or, to discount services if the services are determined to be
				clinically similar to other services on the claim.
(p) Policy Adjustor - Numerical multipliers
				included in the EAPG claim service line payment calculation that increase or
				decrease payments to categories of services, categories of providers, or
				both.
(q) Provider Rate Worksheets
				- A list of the EAPG base rates and automatic rate enhancements for each
				hospital and ASC.
(r) Relative
				Weights - National average values calculated by 3M HIS which identify the
				relative amount of resources utilized to perform the services mapped to the
				EAPG code.
(s) Rural Hospital - As
				defined in section 395.602(2),
				F.S.
(t) Service Line Payment - A
				calculation used to determine individual claim line reimbursement.
(u) Service Line Procedure Code - The
				assigned Common Procedure Terminology© (CPT)
				Code and Health Procedural Code System (HCPCS) included on a claim
				line.