HAR §17-1739-71. Payment for readmission

(a) Readmissions to the same facility within twenty four hours of discharge for the same spell of illness and for the same general diagnosis as the original admission shall be considered to be the same admission and shall be billed as a single stay. The department may deny full or partial payment for the original UNOFFICIAL 1739-25 inpatient stay or the subsequent readmission if it is determined that the facility could have provided all required services during the original inpatient stay. This section shall not apply in cases where a patient leaves the hospital against medical advice. (b) Readmission to the same facility within thirty days of a previous discharge for a similar diagnosis shall be subject to utilization review. The department may deny full or partial payment for the original stay or the subsequent readmission if it is determined that the facility could have provided all required services during the original stay. This section shall not apply in cases where a patient leaves the hospital against medical advice. [Eff 11/13/95 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §447.252) §17-1739-72 Payment for nonpsychiatric cases which exceed $35,000. If charges for nonpsychiatric services rendered to a patient during an inpatient stay are in excess of $35,000, billing and payment for this stay shall be as follows: (1) For classification I facilities and the freestanding rehabilitation hospital, payment shall be made at applicable per diem rates for the full inpatient stay; (2) For classification II and III facilities: (A) An initial interim bill shall be submitted covering the period from the admission date through the date the charge for the case reaches $35,000. Payment for this interim bill shall be the classification per diem rate for the service category multiplied by the number of days covered by the bill plus the full appropriate ancillary rate as calculated in section 17-1739-68; and (B) Sixty days after a patient reaches outlier status, monthly thereafter, and upon discharge, a facility shall bill the department for charges in excess of the outlier threshold. The facility shall also document to the department's reasonable satisfaction the medical necessity for the days of care and services rendered. The department shall pay such bills that are appropriately UNOFFICIAL 1739-26 documented and properly within the scope of the acute care medicaid program no less than quarterly. The department shall pay for the full per diem and eighty per cent of the ancillary charges, excluding amounts included in computing the outlier threshold; and (3) For the purpose of determining capital related costs associated with outlier cases, the full amount of charges shall be included in the facility's computation. [Eff 11/13/95 ] (Auth: HRS §346-59) (Imp: 42 C.F.R. §447.252)