ARM 37.86.2905. INPATIENT HOSPITAL SERVICES, GENERAL REIMBURSEMENT

(1) Prospective payment system (PPS) hospitals including in-state PPS facilities, distinct part units, border facilities, all out-of-state facilities, acute care psychiatric hospitals, and Center of Excellence facilities will be reimbursed under the All Patient Refined Diagnosis Related Groups (APR-DRG) prospective payment system described in ARM 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, and 37.86.2920. (2) Interim reimbursement for cost-based facilities is based on a hospital specific Medicaid inpatient cost-to-charge ratio, not to exceed 100%. Cost-based facilities will be reimbursed their allowable costs as determined according to ARM 37.86.2803. Final cost settlements for CAH facilities will be reimbursed at 101% of allowable costs. (3) Except as otherwise specified in these rules, facilities reimbursed under the APR-DRG prospective payment system may be reimbursed for the following: (a) cost outliers as set forth in ARM 37.86.2916; (b) readmissions, partial eligibility, and transfers, as set forth in ARM 37.86.2918; (c) hospital residents, as set forth in ARM 37.86.2920; (d) disproportionate share hospital payments as provided in ARM 37.86.2925; and (e) hospital reimbursement adjustor payments as provided in ARM 37.86.2928. (4) PPS facilities may interim bill for stays equal to or exceeding 30 days at the same hospital. (a) The interim rate will be a flat per diem rate times the number of covered days for the claim. (b) Upon discharge the interim claims will be voided or credited by the hospital and the hospital must bill a single admit through discharge claim which will be paid by APR-DRG. (c) The hospital must obtain authorization to interim bill prior to submission of the first claim and must provide medical records upon request of the department or the department's designated review organization for continued stay reviews. (5) The Medicaid statewide average PPS inpatient cost to charge ratio including capital expenses is 52%. (6) The Medicaid statewide average cost based inpatient cost to charge ratio including capital expenses is 53%.