reglab/statecodes huggingface dataset:
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 11 - CHARITY CARE › Section 10:52-11.13 - Application and determination

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Consistent with the requirements of N.J.A.C. 10:52-11.6, 11.7, 11.8, 11.9, 11.10, 11.11, and 11.12, the Department of Health shall specify the elements to be included in charity care application and eligibility determination forms used by all disproportionate share hospitals for the Charity Care Program; hospitals shall not omit or add to these elements. The application form shall advise patients of the penalties for providing false information on a charity care application. The list of required elements may be obtained from the Department of Health, Division of Health Services Oversight, Hospital Financial Reporting and Support.
(b) An applicant or responsible party may submit a completed application for a hospital to make a determination for charity care or reduced charge charity care at any time up to one year from the date of outpatient service or inpatient discharge. The hospital shall make the charity care determination and notify the applicant in writing, as soon as possible, but no later than 10 working days from the day the applicant submits a completed initial application. If the application does not include sufficient documentation to make the determination, the hospital shall notify the applicant, in writing, as soon as possible, but no later than 10 working days from the day the applicant submits an incomplete application. The applicant shall be permitted to supply additional documentation at any time up to one year after the date of discharge (inpatient) or service (outpatient). At the hospital's discretion, the hospital may accept a completed application within two years of the date of service (outpatient) or date of discharge (inpatient).
(c) A determination that an applicant is eligible shall indicate:
1. The date on which the eligibility determination was made;
2. The date on which hospital services were requested;
3. The date on which the services were or will be provided to the applicant;
4. That the facility will provide charity care services at no charge or at a specified charge which is less than the allowable charge for the services;
5. The applicant's family size, income and eligibility computation;
6. The length of time that the hospital will provide charity care based on this determination. A hospital shall not provide charity care on the basis of a determination of eligibility that is more than one year old; and
7. The name and telephone number of a person a hospital can contact to verify eligibility.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 11 - CHARITY CARE › Section 10:52-11.14 - Collection procedures and prohibited action

Current through Register Vol. 56, No. 14, July 15, 2024
Persons determined to be eligible for charity care shall not receive a bill for services or be subject to collection procedures. Persons determined to be eligible for reduced charge charity care shall not be billed or subject to collection procedures for the portion of the bill that is reduced charge charity care.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 11 - CHARITY CARE › Section 10:52-11.15 - Adjustment methodology

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The following words and terms, when used in this section, shall have the following meanings, unless the context clearly indicates otherwise:
"Alternative documentation adjustment" means an adjustment to a hospital's charity care write-off amount as a result of the periodic audits of a sample of claims submitted during a calendar year. This audit determines whether the total value of sampled claims that are documented by the alternative procedures described in 10:52-11.6(a)3, 11.7(a)3, 11.9(a)3 or 11.10(d)3, exceeds permitted limits.
"Charity care write-off amount" means the rendered charity care services, priced at the rate used by the Medicaid program before adjustment, if any, for direct graduate medical education and indirect medical education factors.
"Compliance adjustment" means an adjustment to a hospital's charity care write-off amount as a result of the periodic audits of a sample of claims submitted during a calendar year. This audit determines whether there is appropriate documentation showing that all charity care eligibility requirements at 10:52-11.5 through 11.11 and 11.16 have been met.
"Listing adjustment" means an adjustment to a hospital's charity care write-off amount as a result of the audit of a sample of these claims submitted during a calendar year. The purpose of this audit is to ensure that the claims contain only those charges that are eligible for reimbursement.
(b) The charity care write-off amount for each account should agree with the reimbursement rate that would have been paid to the hospital by the Medicaid/NJ FamilyCare program. To the extent that a hospital's total charity care write-off amount is overstated, the amount will be reduced by the amount of the overstatement.
(c) In addition to adjustments required to ensure that the charity care write-off amount is equal to the Medicaid/NJ FamilyCare reimbursement rates, the write-off amount may also be revised on the basis of listing, alternative documentation and/or compliance adjustments, in that order.
(d) Examples of listing adjustments include changes made if:
1. Medicare or other third-party payer payments were not reflected in the claim;
2. Ineligible expenses, such as standard convenience or personal comfort items as listed in Uniform Billing requirements, are included; or
3. The percentage of the claim to be written off to charity care, based on the hospital's determination of the applicant's eligibility, was erroneous.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 11 - CHARITY CARE › Section 10:52-11.16 - Charity care applications of patients admitted through emergency room

Current through Register Vol. 56, No. 14, July 15, 2024
(a) If a charity care applicant is admitted through the hospital's emergency room, the requirements set forth in this section shall apply.
1. The hospital shall notify the patient, orally and by providing a copy of the individual written notice referenced in 10:52-11.5(a), of the availability of charity care. This notice shall be given prior to the patient's discharge from the hospital.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 12 - CHARITY CARE COMPONENT OF THE DISPROPORTIONATE SHARE HOSPITAL SUBSIDIES › Section 10:52-12.1 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
The following words and terms, when used in this subchapter, shall have the following meanings, unless the context clearly indicates otherwise:
"Adjudication" means the processing of all submitted claims accepted by the Fiscal Agent during a monthly adjudication cycle, with the outcome being the claim is priced, denied, or processed as a void or adjustment of a previous claim. Voids and adjustments are also either priced or denied.
1. Claims included in files that are rejected during preprocessing are not adjudicated because the claims never enter the system for pricing.
2. Adjudicated claims are reported monthly to the hospital or the hospital's designated agent on the Remittance Advice.
"Adjudication cycle date" is the date on which claims are accepted for pricing by the Fiscal Agent and are adjudicated.
"Clean charity care claim" means a charity care claim that is received by the Fiscal Agent and accepted by the Fiscal Agent in accordance with electronic media procedures and is adjudicated and priced no later than two years after the date of patient discharge (inpatient) or date of service (outpatient). Claims that are denied are not clean claims. A clean charity care claim includes:
1. The name and provider number assigned by the Department of Health to each licensed hospital;
2. The name and, if available, Social Security number of the charity care eligible recipient of the services;
3. The diagnosis(es);
4. The date of service for outpatient services or dates of admission and discharge for inpatient services;
5. The services rendered and the charge for the service; and
6. The data required by the Fiscal Agent in accordance with the Fiscal Agent Billing Supplement, provided that the requirement is not in conflict with the provisions of the New Jersey Administrative Code.
"Pricing cycle" means the Fiscal Agent's charity care claims submission schedule, as described in 10:52-12.2(c).
"Remittance Advice (RA)" means the hospital's account statement of activity for the most recent monthly adjudication cycle which reflects the status of all charity care claims, tracked according to a unique Internal Control Number (ICN), adjudicated by the Fiscal Agent during that cycle.
"Submission cut-off date" means the date by which claims shall be received by the Fiscal Agent to assure processing for and possible adjudication in the pricing cycle.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 12 - CHARITY CARE COMPONENT OF THE DISPROPORTIONATE SHARE HOSPITAL SUBSIDIES › Section 10:52-12.3 - Basis of pricing for charity care claims

Current through Register Vol. 56, No. 14, July 15, 2024
(a) All hospital outpatient and inpatient charity care claims shall be priced based on the New Jersey Medicaid/NJ FamilyCare program's pricing and program policies for hospital outpatient and inpatient hospital services. (See this chapter, and, specifically, NJ.A.C. 10:52-1.6, Covered services (inpatient and outpatient services), and 10:52-4, Basis of Payment.)
1. Exception: Although the New Jersey Medicaid/NJ FamilyCare program reimburses dental services on a fee-for-service schedule for outpatient hospital charity care claims, dental services shall be priced based on hospital outpatient cost to charge ratio as described in N.J.A.C. 10:52-4.3. All other hospital outpatient services for charity care shall also be priced according to the Medicaid/NJ FamilyCare hospital outpatient methodology. (See N.J.A.C. 10:52-4.3.)
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 13 - ELIGIBILITY FOR AND BASIS OF PAYMENT FOR DISPROPORTIONATE SHARE HOSPITALS › Section 10:52-13.1 - Disproportionate share adjustment-general eligibility

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A disproportionate share hospital (DSH) shall be a hospital designated as such by the Commissioner of the Department of Human Services. At a minimum, each hospital with a Medicaid/NJ FamilyCare inpatient hospital utilization rate that is one standard deviation above the mean Medicaid/NJ FamilyCare utilization rate for hospitals receiving Medicaid/NJ FamilyCare payments in the State, and every hospital with a low-income utilization rate above 25 percent will be treated as a disproportionate share hospital.
(b) The Commissioner of the Department of Human Services may designate additional hospitals as disproportionate share hospitals if it is determined they serve a large number of low-income mentally ill or developmentally disabled clients.
(c) The Commissioner of the Department of Human Services may make additional disproportionate share payments to facilities operating under 18A:64G-1 et. seq. providing a high level of charity and uncompensated care to low-income persons and persons with special needs.
(d) The Commissioner of the Department of Human Services may also designate a hospital as eligible for additional disproportionate share payments if it is determined that the hospital provides a high percentage of care (as defined in N.J.A.C. 10:52-13.5) in proportion to total operating revenue to patients with HIV, mental illness, tuberculosis, substance abuse and addiction, complex neonates, HIV as a secondary diagnosis, and mothers with substance abuse. In addition, to be designated as eligible for this additional disproportionate share payment, the facility shall have a high Charity Care plus Medicaid/NJ FamilyCare utilization rate (as defined in N.J.A.C. 10:52-13.5).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 13 - ELIGIBILITY FOR AND BASIS OF PAYMENT FOR DISPROPORTIONATE SHARE HOSPITALS › Section 10:52-13.2 - Disproportionate share hospital (DSH) payment-general

Current through Register Vol. 56, No. 14, July 15, 2024
The disproportionate share adjustment shall include an adjustment amount annually determined, as to N.J.A.C. 10:52-13.4, by the Commissioner, Department of Health in consultation with the Commissioner, Department of Human Services and, as to N.J.A.C. 10:52-13.3, 13.5, 13.6, and 13.7 by the Commissioner, Department of Human Services based upon a determination regarding payments for charity care. The annual DSH payments shall be calculated and distributed in accordance with all applicable Federal laws and regulations
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 13 - ELIGIBILITY FOR AND BASIS OF PAYMENT FOR DISPROPORTIONATE SHARE HOSPITALS › Section 10:52-13.3 - Eligibility and disproportionate share hospital payments for hospitals operating under

Current through Register Vol. 56, No. 14, July 15, 2024
N.J.S.A. 18A:64G-1For facilities operating under N.J.S.A. 18A:64G-1et seq., the disproportionate share allocation may be increased by an amount recommended by the Office of Management and Budget which will consider the total operating cost of the facility less any third-party payments, including all other Medicaid/NJ FamilyCare payments, as well as payments from non-State sources for services provided by the hospital during the hospital's fiscal year.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 13 - ELIGIBILITY FOR AND BASIS OF PAYMENT FOR DISPROPORTIONATE SHARE HOSPITALS › Section 10:52-13.4 - Eligibility for disproportionate share hospital payments from the Charity Care Component of the Health Care Subsidy Fund

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The recommendation from the Department of Health shall be calculated in the following manner pursuant to N.J.S.A. 26:2H-18.
1. The determination of the value of the Charity Care Component of the Health Care Subsidy Fund shall be calculated in the following manner:
i. The Department of Health shall use the results of the charity care audit conducted as its definition of charity care incurred by all hospitals.
ii. The New Jersey Department of Health shall report the results of its audit of New Jersey acute care hospital's charity care that was conducted in accordance with N.J.A.C. 10:52-11 to the Division of Medical Assistance and Health Services.
(1) For purposes of determining annual charity care costs, the criteria in N.J.A.C. 10:52-11shall not apply to a patient who is investigated by a county adjuster and found to be indigent by a court of competent jurisdiction pursuant to 30:4-1 et seq. A patient so found shall qualify for 100 percent charity care coverage. Hospitals with patients who qualify under this provision shall include the appropriate documentation from the court in the patient's file for audit.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 13 - ELIGIBILITY FOR AND BASIS OF PAYMENT FOR DISPROPORTIONATE SHARE HOSPITALS › Section 10:52-13.5 - Eligibility for and payment of Hospital Relief Subsidy Fund DSH

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Hospitals eligible for additional disproportionate share payments may receive an additional payment determined by the Commissioner of the Department of Human Services from the Hospital Relief Subsidy Fund. This additional payment shall be based upon the facility's percentage of clients with HIV, mental health, tuberculosis, substance abuse and addiction, complex neonates, HIV as a secondary diagnosis, and mothers with substance abuse.
1. Effective for periods after State Fiscal Year 1999, payments from the Hospital Relief Subsidy Fund shall be calculated and distributed to eligible disproportionate share hospitals, if funds are available, using the most recent calendar year hospital data available as of February 1 of each State fiscal year preceding the distribution year. For the purpose of pricing the problem billed cases listed at (a)1ii(1) below effective on or after July 6, 1998, the Medicaid/NJ FamilyCare rate shall be defined as the rate in effect as of February 1 of each State fiscal year preceding the distribution year. Effective for payments on or after July 6, 1998, this payment shall no longer be distributed over a Calendar Year. Instead, it shall be distributed over the State Fiscal Year, July through June.
i. For purposes of determining which hospitals are eligible for payment from the HRSF, a hospital shall satisfy both of the two following independent criteria:
(1) The hospital's cases for the seven categories listed at (a)1ii(1) below, priced at the Medicaid/NJ FamilyCare rate, divided by the hospital's Total Operating Revenue, expressed as a percentage, shall be equal to or greater than the median percentage for New Jersey Hospitals receiving Medicaid/NJ FamilyCare payments. For periods in which the data source excludes GME and IME in the rate, the Medicaid rate shall be adjusted by a hospital-specific GME and IME add-ons. The hospital-specific GME and IME add-ons shall be calculated as defined in (a)1iv below; and
(2) The hospital's charity care days plus the hospital's Medicaid/NJ FamilyCare-Plan A days, divided by the hospital's total days, expressed as a percentage, shall be equal to or greater than the median percentage for New Jersey hospitals receiving Medicaid/NJ FamilyCare-Plan A payments. For payments distributed in State Fiscal Years after State Fiscal Year 1999, the hospital's Medicaid days shall include Medicaid FamilyCare-Plan A managed care days if the data is available by February 1 prior to the State fiscal year of distribution.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 13 - ELIGIBILITY FOR AND BASIS OF PAYMENT FOR DISPROPORTIONATE SHARE HOSPITALS › Section 10:52-13.6 - Eligibility and payment for DSH funding from the Hospital Subsidy Fund for Mentally Ill and Developmentally Disabled Clients

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Disproportionate Share Hospitals which service a large number of low-income mentally ill or developmentally disabled clients may also be eligible to receive increased disproportionate share payments. The amount of payment to be made to facilities which serve a large number of mentally ill low-income clients will be based upon recommendation by the Division of Mental Health and Addiction Services (DMHAS) within the Department of Human Services to the Commissioner of the Department of Human Services. This recommendation will identify hospitals essential to preserve the fragile network of mental health providers in the State. The Division of Developmental Disabilities may also recommend an additional payment to facilities that serve a large number of developmentally disabled clients. These additional payments will assure that these low-income and special needs clients continue to have access to critical care.
1. The Hospital Subsidy Fund for Mentally Ill and Developmentally Disabled Clients shall be an amount allocated by the Commissioner during the fiscal year for this purpose. It shall be distributed in the following manner:
i. Hospitals who receive funding from the Hospital Relief Subsidy Fund shall only be eligible for a payment from this fund if recognized by the Division of Mental Health and Addiction Services as a Short-Term Care Facility (STCF) or a Child Community Inpatient Serviced STCF and CCIS shall be based upon its distribution of beds for these services times a projection of the cost of providing the service in a state facility. Any hospital adding these beds will be eligible for payments from this fund. The initial redistribution of the funds among eligible hospitals will be carried out in August, 1994. In subsequent years, the redistribution will be carried out in January of each year but may be redistributed on a quarterly basis as new beds are added or removed from service, at the discretion of DMHAS.
ii. Hospitals who are not a STCF or CCIS, but which are under contract with the Division of Mental Health and Addiction Services shall receive an allocation of funds based upon the percentage of services provided by the hospital as a percentage of all services provided by all hospitals. The initial redistribution of the funds among eligible hospitals will be carried out in August, 1994. In subsequent years, the redistribution will be carried out in January of each year but may be redistributed on a quarterly basis as new beds are added or removed from service, at the discretion of DMHAS.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.1 - Effective date

Current through Register Vol. 56, No. 14, July 15, 2024
(a) Effective for inpatient services with discharge dates on or after August 3, 2009, general acute care hospitals will be paid in accordance with the New Jersey Medicaid Diagnosis Related Groups (DRG) Reimbursement System described in this subchapter.
(b) If the initial rate year is a partial year, all rate setting components used to calculate inpatient reimbursement delineated below will remain the same for the second rate year, except that the final rates will be increased by the economic factor applicable to that rate year as described in 10:52-14.6(c). For the third and subsequent rate years, the Statewide base rate will not change until rebasing occurs as explained in 10:52-14.6(e), add-on amounts will be calculated annually in accordance with 10:52-14.7, and the DRG weights will not change until recalibration occurs as delineated in 10:52-14.3.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.2 - Definitions

Current through Register Vol. 56, No. 14, July 15, 2024
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.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.3 - Calculation of the DRG weights

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A Statewide relative weight for each DRG was developed using the most recent available audited Medicare cost report data and Medicaid/NJ FamilyCare paid claims data for the same year. The cost data used excludes direct and indirect medical education costs. In the initial rate year, 2003 audited Medicare cost report data and 2003 Medicaid/NJ FamilyCare claim data were used to develop the DRG weights.
(b) Charges from the Medicaid/NJ FamilyCare claims were converted to cost by multiplying the routine cost center per diem costs from the Medicare cost reports times the number of routine days from the Medicaid/NJ FamilyCare claims using a hospital specific crosswalk between revenue codes and hospital cost centers, and multiplying the ancillary cost center cost-to-charge ratios from the Medicare cost reports times the ancillary charges from the Medicaid/NJ FamilyCare claims using a hospital specific crosswalk between revenue codes and hospital cost centers.
(c) The calculated routine and ancillary costs were aggregated by DRG and were used to develop total Statewide costs for each DRG.
(d) The formula used to calculate a DRG weight is as follows: the Statewide average cost per inlier case for a specific DRG divided by the Statewide average cost per inlier case for all DRGs.
(e) DRGs that did not have sufficient Medicaid/NJ FamilyCare claim volume to develop a statistically valid weight using the DRG weight setting methodology in (d) above had a weight derived from additional sources. For these DRGs, charity care claim volume was added to the Medicaid/NJ FamilyCare claim volume using the methodology in (d) above to establish a stable DRG weight. In cases where using this secondary data set did not yield a stable DRG weight, the normalized DRG weight from the corresponding New York AP DRG Grouper was used.
(f) An annual inflation factor was used to calculate inflation of routine and ancillary cost data. The inflation factor used was the excluded hospital market basket percentage increase, which is used by the Center for Medicare and Medicaid Services (CMS) for hospitals excluded from its Inpatient Prospective Payment System (IPPS), and is published in the Federal Register annually by CMS. The excluded hospital inflation factor has also been referred to as the economic factor recognized under the CMS Tax Equity and Fiscal Responsibility Act, Pub.L. 97-248, (TEFRA) target limitations.
1. Routine costs were inflated from the midpoint of the provider's cost report period to the midpoint of the rate year.
2. Ancillary costs were inflated from the last date of services provided to the midpoint of the rate year.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.5 - Statewide base rate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division determined a single Statewide base rate, referred to as the "Statewide base rate," for all general acute care hospitals as described in 10:52-14.6.
(b) The Statewide base rate is used in conjunction with increases to the Statewide base rate referred to as add-on amounts, DRG relative weights and other components defined in this subchapter, which were developed for the New Jersey DRG reimbursement system to determine the total payment for each discharge.
(c) Except for the initial rate year and in rate years in which rebasing occurs, the Statewide base rate will not change except for inflation increases as described in 10:52-14.6(c).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.6 - Determination of the Statewide base rate

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division established an initial Statewide base rate, which applies to all hospitals. Those hospitals meeting the criteria for add-on amounts in accordance with N.J.A.C. 10:52-14.7have rates higher than the Statewide base rate. The initial Statewide base rate is established as follows:
1. For the initial rate year, the Division used the actual payments made for claims paid during calendar year 2006. Total payments include all DRG and outlier payments. Payments for hospital-based physicians were removed since hospital-based physician groups will bill for these services separately beginning August 3, 2009. These historical 2006 payments were inflated to the rate year by applying the excluded hospital inflation factor, also referred to as the economic factor recognized under the Center for Medicare and Medicaid Services (CMS) Tax Equity and Fiscal Responsibility Act, Pub.L. 97-248 (TEFRA) target limitations, which is published annually in the Federal Register by CMS. These adjusted payments were used to establish the total budgeted amount for inpatient acute hospital services for the rate year.
2. The amount calculated in (a) above is reduced to account for the following DRG system payments: addon amounts under N.J.A.C. 10:52-14.7, outlier payments, payments for alternate levels of care and the effect on payments where Medicaid/NJ FamilyCare is not the primary payer (that is, Medicare claims partially paid by Medicaid/NJ FamilyCare and third party liability claims). A reduction in payments was also made to remove an amount for utilization review services that were previously paid for by hospitals, which will become a State obligation, effective August 3, 2009.
i. If the Division does not have a contractor for hospital utilization review services by August 3, 2009, hospitals will receive separate payments equal to the aggregate amount of utilization review removed before establishing the Statewide base rate. Each hospital will receive a utilization review payment based on its proportional amount of Medicaid/NJ FamilyCare fee-for-service discharges from the most recent available 24 months of Medicaid/NJ FamilyCare paid claims data. The allocation of utilization review payments will account for closed hospitals in accordance with the method set forth in N.J.A.C. 10:52- 14.7(d).
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.8 - DRG daily rates

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The Division will calculate DRG daily rates for each DRG for each hospital. These rates are used for calculating reimbursement in cases involving transfers, same-day discharges, and for cases in which Medicaid/NJ FamilyCare eligibility began or ended during the inpatient stay.
(b) The DRG daily rate is calculated for each DRG as follows: the hospital's final rate multiplied by the DRG weight divided by the geometric mean length of stay. The geometric mean length of stay is rounded to the nearest whole number.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.9 - Hospital specific Medicaid/NJ FamilyCare cost-to-charge ratios

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For the initial rate year and every year thereafter, the Division will calculate hospital-specific initial inpatient cost-to-charge ratios (CCR) using the most recent available submitted Medicare cost report data.
(b) The hospital-specific CCRs are calculated using total cost, total inpatient charges and total charges by cost center from the most recent available submitted Medicare cost report Worksheet C. Inpatient costs are estimated by developing the percent of inpatient charges to total charges for each cost center and multiplying that percentage times the total costs in that cost center; total inpatient costs are the sum of the inpatient costs for all cost centers. The inpatient CCR is calculated by dividing total inpatient costs by total inpatient charges.
(c) The hospital-specific CCRs are used to estimate the cost of claims for determining whether the hospital's inpatient claims exceed the cost outlier threshold in accordance with 10:52-14.11 and also to calculate the cost outlier payments.
(d) The Division will monitor charges and payments from current claims on an ongoing basis and adjust the CCRs and payments as needed during the rate year to ensure appropriate payments. Adjustment of payments would include repricing Medicaid/NJ FamilyCare claims for the rate year.
(e) Hospitals shall notify the Division of any changes made to the hospital's charge structure. Notice shall be given 30 days prior to implementation of the change, in writing, addressed to:
Office of Reimbursement
Division of Medical Assistance and Health Services
Mail Code #44
P.O. Box 712
Trenton, NJ 08625-0712
(f) In cases in which a hospital failed to notify the Division of changes to the hospital's charge structure 30 days prior to implementation, the hospital shall pay for all costs associated with reprocessing its claims, as well as the recovery of the related overpayments and interest related to those overpayments. Reprocessing shall apply to both Medicaid/NJ FamilyCare and charity care claims. Repeated occurrences of the failure to timely notify the Division of hospital CCR changes will be forwarded to the State's Medicaid Inspector General for review and possible referral to the Office of the Attorney General's Division of Criminal Justice for legal action.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.10 - Standard DRG payment calculation

Current through Register Vol. 56, No. 14, July 15, 2024
The standard DRG payment is the hospital's final rate multiplied by the DRG weight.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.11 - Cost outlier payment calculation

Current through Register Vol. 56, No. 14, July 15, 2024
(a) A cost outlier is defined as an inpatient stay with an estimated cost, which exceeds the greater of the State designated cost outlier threshold or the cost outlier statistical limit for a certain DRG. The cost outlier calculation is set forth in (e) below.
(b) The cost outlier statistical limit is the statistical limit for each DRG, defined as the sum of the Statewide average cost per stay for that DRG, and 1.96 times the standard deviation of the Statewide average cost per stay for that DRG.
(c) The cost outlier threshold is the fixed dollar amount cost outlier limit established by the Division, which applies to all DRGs. Applying this threshold in the cost outlier calculation assures that no cost outlier payments will be made for any DRG with a cost outlier statistical limit less than the threshold amount.
(d) The marginal cost percentage is the State-designated percentage used to determine the proportion of estimated cost that will be reimbursed as a cost outlier payment as described in (e) below. The State-designated marginal cost percentage applies to all DRGs and all hospitals.
(e) To calculate the estimated cost of a claim, the hospital's cost-to-charge ratio (CCR) is multiplied by the total covered charges on the claim. If the estimated cost amount exceeds the higher of the statistical cost outlier limit for the assigned DRG or the State-designated cost outlier threshold amount, the hospital will receive a cost outlier payment. The amount of the estimated cost in excess of the applicable cost outlier threshold or cost outlier statistical limit is multiplied by the marginal cost percentage. The resulting amount is the cost outlier payment.
(f) The cost outlier payment is made to the hospital in addition to the standard DRG payment amount.
(g) For claims with alternate level of care days, charges used to calculate cost outlier payments do not include routine per diem charges for alternate level of care days.
(h) The hospital specific CCRs used to develop the final rates were calculated using 2003 audited Medicare cost report data and 2003 claims data. Specifically, the 2003 CCRs were derived from the process used to convert charges to cost for calculating the DRG weights, as described in 10:52-14.3. In the initial rate year, the hospital specific CCRs used to calculate cost outlier payments were calculated using the most recent available submitted Medicare cost report data, subject to review and adjustment by the Division if necessary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.12 - Day outlier payment calculation for alternate level of care days

Current through Register Vol. 56, No. 14, July 15, 2024
(a) The day outlier calculation only applies to claims in which there are alternate level of care days (for example, skilled nursing facility, intermediate care facility). This calculation is only used to determine qualification for payment of nursing facility days for those claims with days at an alternate level of care awaiting placement in a non-acute facility.
(b) For a total length of stay on the claim, which is higher than the day outlier limit for the assigned DRG, a day outlier payment will be made to the hospital for only those days that both exceed the day outlier limit and are classified as days awaiting placement in an alternative level of care.
(c) The day outlier payment is the number of alternate level of care days from the formula in (b) above multiplied by the annual nursing facility per diem rate set by the Facility Rate Setting program of the Division of Aging Services in the Department of Human Services.
(d) The day outlier limit is calculated for each DRG as follows: the geometric mean length of stay of the DRG plus 1.96 standard deviations of the geometric mean length of stay of the DRG, excluding any alternate level of care days. The day outlier limit is rounded to the nearest whole number.
(e) The day outlier payment is made to the hospital in addition to the standard DRG payment amount.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.13 - Simultaneous cost outlier and day outlier payments

Current through Register Vol. 56, No. 14, July 15, 2024
If a covered hospital inpatient stay is determined to be eligible for both a cost outlier and a day outlier payment, the total reimbursement will be the sum of the standard DRG payment, the cost outlier payment and the day outlier payment.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.14 - Payment for transfers

Current through Register Vol. 56, No. 14, July 15, 2024
(a) When a patient is transferred during a covered general acute care hospital inpatient stay from one hospital to another hospital, the reimbursement to the general acute care hospitals involved in the transfer(s) will be calculated as follows:
1. The reimbursement to each transferring general hospital will be the DRG daily rate for each covered day of stay. Total payment to each transferring hospital will be no greater than the standard DRG payment, except where the transferring hospital is eligible for an outlier payment;
2. The receiving acute care general hospital will be reimbursed the standard DRG payment. If the claim qualifies as an outlier, the receiving hospital will be eligible for outlier payments based solely on the stay at the receiving hospital; and
3. Transfer cases, both transferring and receiving, that are cost or day outliers shall be subject to the Division's utilization review to determine whether the outlier payment is medically necessary.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.15 - Payment for same day discharges

Current through Register Vol. 56, No. 14, July 15, 2024
In cases where the patient has been admitted and is discharged on the same day, reimbursement will be paid at the DRG daily rate.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Subchapter 14 - METHODOLOGY FOR ESTABLISHING DRG PAYMENT RATES FOR INPATIENT SERVICES AT GENERAL ACUTE CARE HOSPITALS BASED ON DRG WEIGHTS AND A STATEWIDE BASE RATE › Section 10:52-14.16 - Payment for readmissions

Current through Register Vol. 56, No. 14, July 15, 2024
(a) For New Jersey hospitals, if a patient is readmitted to the same hospital for the same or similar diagnosis within seven days, the second claim submitted for payment will be denied. For dates of service before October 1, 2015, the same or similar principal diagnosis is defined as principal diagnoses with the same first three digits in accordance with the International Classification of Diseases, 9th Edition, Clinical Modification published by Practice Management Information Corporation. For dates of service on or after October 1, 2015, the same or similar principal diagnosis is defined as principal diagnoses in the same clinical diagnosis group, determined by the range in which the first three characters of the diagnosis code fall (for example, A00 - B99 is a clinical diagnosis group entitled "Certain infectious and parasitic diseases") in accordance with the International Classification of Diseases, 10th Revision, with Clinical Modifications (ICD-10-CM). For these readmissions, requests for payment of services related to the two hospital inpatient stays shall be combined on the same claim form for reimbursement purposes.
1. In the event that one claim has a date of service prior to October 1, 2015, and another claim has a date of service on or after October 1, 2015, the principal diagnosis reported on the first claim as an International Classification of Diseases, 9th Revision, with Clinical Modifications (ICD-9-CM) diagnosis code, is compared to the principal diagnosis reported on the other claim as an International Classification of Diseases, 10th Revision, with Clinical Modifications (ICD-10-CM) diagnosis code, using the Centers for Medicare and Medicaid Services (CMS) General Equivalency Mapping (GEM) criteria, 2014 Version, which is incorporated herein by reference, as amended and supplemented. Information regarding the CMS GEM can be found at
http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html
.
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Appendix A

Current through Register Vol. 56, No. 14, July 15, 2024
FISCAL AGENT BILLING SUPPLEMENT
AGENCY NOTE: The Fiscal Agent Billing Supplement is appended as a part of this chapter but is not reproduced in the New Jersey Administrative Code. When revisions are made to the Fiscal Agent Billing Supplement a revised version will be made available at
www.njmmis.com
and copies will be filed with the Office of Administrative Law. The Fiscal Agent Billing Supplement may be reviewed and downloaded free of charge by accessing the following website:
www.njmmis.com
. For a paper copy of the Fiscal Agent Billing Supplement, write to:
UNISYS
PO Box 4801
Trenton, New Jersey 08619-4801
or contact:
Office of Administrative Law
Quakerbridge Plaza, Building 9
PO Box 049
Trenton, New Jersey 08625-0049
New Jersey Administrative Code › Title 10 - HUMAN SERVICES › Chapter 52 - HOSPITAL SERVICES MANUAL › Appendix B

Current through Register Vol. 56, No. 14, July 15, 2024
EMC MANUAL
AGENCY NOTE: The Electronic Media Claims (EMC) Manual is appended as a part of this chapter but is not reproduced in the New Jersey Administrative Code. When revisions are made to the EMC Manual a revised version will be made available at
www.njmmis.com
and copies will be filed with the Office of Administrative Law. The EMC Manual may be reviewed and downloaded free of charge by accessing the following website:
www.njmmis.com
. For a paper copy of the EMC Manual, write to:
UNISYS
PO Box 4801
Trenton, New Jersey 08619-4801