Arizona Administrative Code › Title 9 - HEALTH SERVICES › Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION › Article 7 - STANDARDS FOR PAYMENTS › Section R9-22-712.01 - Inpatient Hospital Reimbursement for Claims with Admission Dates and Discharge Dates from October 1, 1998 through September 30, 2014

Current through Register Vol. 30, No. 28, July 12, 2024
Inpatient hospital reimbursement. The Administration shall
				  pay for covered inpatient acute care hospital services provided to eligible
				  persons for claims with admission dates and discharge dates from October 1,
				  1998 through September 30, 2014, on a prospective reimbursement basis. The
				  prospective rates represent payment in full, excluding quick-pay discounts,
				  slow-pay penalties, and third-party payments for both accommodation and
				  ancillary department services. The rates include reimbursement for operating
				  and capital costs. The Administration shall make reimbursement for direct
				  graduate medical education as described in A.R.S. §
									36-2903.01.
				  For payment purposes, the Administration shall classify each AHCCCS inpatient
				  hospital day of care into one of several tiers appropriate to the services
				  rendered. The rate for a tier is referred to as the tiered per diem rate of
				  reimbursement. The number of tiers is seven and the maximum number of tiers
				  payable per continuous stay is two. Payment of outlier claims, transplant
				  claims, or payment to out-of-state hospitals, freestanding psychiatric
				  hospitals, and other specialty facilities may differ from the inpatient
				  hospital tiered per diem rates of reimbursement described in this
				  Section.
1. Tier rate data. The
				Administration shall base tiered per diem rates effective on and after October
				1, 1998 on Medicare Cost Reports for Arizona hospitals for the fiscal year
				ending in 1996 and a database consisting of inpatient hospital claims and
				encounters for dates of service matching each hospital's 1996 fiscal year end.
a. Medicare Cost Report data. Because
				Medicare Cost Report years are not standard among hospitals and were not
				audited at the time of the rate calculation, the Administration shall inflate
				all the costs to a common point in time as described in subsection (2) for each
				component of the tiered per diem rates. The Administration shall not make any
				changes to the tiered per diem rates if the Medicare Cost Report data are
				subsequently updated or adjusted. If a single Medicare Cost Report is filed for
				more than one hospital, the Administration shall allocate the costs to each of
				the respective hospitals. A hospital shall submit information to assist the
				Administration in this allocation.
b. Claim and encounter data. For the
				database, the Administration shall use only those inpatient hospital claims
				paid by the Administration and encounters that were accepted and processed by
				the Administration at the time the database was developed for rates effective
				on and after October 1, 1998. The Administration shall subject the claim and
				encounter data to a series of data quality, reasonableness, and integrity edits
				and shall exclude from the database or adjust claims and encounters that fail
				these edits. The Administration shall also exclude from the database the
				following claims and encounters:
i. Those
				missing information necessary for the rate calculation,
ii. Medicare crossovers,
iii. Those submitted by freestanding
				psychiatric hospitals, and
iv.
				Those for transplant services or any other hospital service that the
				Administration would pay on a basis other than the tiered per diem
				rate.