9c - __01_15

CYE 15 APR-DRGImplementation
The APR-DRGpayment methodologywillbe implemented for all acute/generalhospitals (provider type 02)The same payment methodology will be used for both in-andout-of-state hospitalsRehaband Long Term Care hospitals will be split to a new provider type and will continue topaid under a perdiemrate methodologySelect transplants will continue to be carved out into bundled payment contracts
CYE 15 APR-DRG Implementation –Select Payment Policies
Capitation rate impacts are under review for all policy decisionsPricing logic under APR-DRG (DRG) will be based on discharge dateThus payer at date of discharge is responsible for payment of all Medicaid covered days during the inpatient stayDates of discharge on and after 10/1/14 will be paid at DRGPotentiallypreventable readmissionswill not be paid, as follows:Readmissionswithin 72 hours to the same hospital with the same base DRG assignment will be pended to medicalreviewIfthe readmission is determined to have been preventable, payment will bedisallowed
CYE 15 APR-DRG Implementation –Select Payment Policies
Due to the characteristics of the AHCCCS population, administrative days will be covered, only when prior authorized and based on negotiated per diem rates(Medicare does not cover under CMS DRGs)Interimbilling will be permitted in 30 dayincrementsInterimbills will be reimbursed at $500 perdayInterimbills must be voided and a final replacementadmission through discharge billmust be submitted at discharge encompassing all daysbilledasinterim and covered by MedicaidInterimpayments will be recouped and the final bill paid atAPR-DRGPost-paymentaudits may be performed to ensure providers submit the finalbill per these guidelines
CYE 15 APR-DRG Implementation –Select Payment Policies
All claims with an admission date matching theend date of service with a patient status of discharge/transfer willbe reimbursed underthe existing OPFSmethodology including same day admit/discharge maternity/newbornclaims (thus eliminating the current lessor of evaluation)MCO vs. RBHA payment - if the member’sprimary diagnosisis:amedicaldiagnosis,then AHCCCS/MCOs will pay underDRG (unless otherwise contracted)a behavioral diagnosis,then the RBHAs will pay under the currentper diemmethodology(unlessotherwise contracted)Hospitalsmust start a new claim for the behavioral healthportion ofthe patientstay after a member is medically stabilized and transferred within the facility
CYE 15 APR-DRG Implementation –Select Payment Policies
Prorated pricing of claims will occur for stays including, but not limited to:TransfersMember gains eligibility for AHCCCS after admissionMember loses eligibility for AHCCCS before dischargeProration methodology differs depending on the situation though payment will never exceed a full DRG payment
CYE 15 APR-DRG Implementation –Reinsurance Policy Changes
Capitation rate impacts are under review for allreinsurance policy changesEncounters that includePPCdayswill notbe eligible for reinsuranceMCOswill not be permittedtosplitsuch encountersEncounters for interim bills will not be eligible for reinsuranceThefinalencounters replacing interim bills will be eligible for reinsurance unlesstheclaims cross contract yearsEncountersthatcross contractyears will not be eligible forreinsuranceMCOswill not be permitted to splitsuch encounters