Arizona Administrative Code
Title 9 - HEALTH SERVICES
Chapter 22 - ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM - ADMINISTRATION
Article 7 - STANDARDS FOR PAYMENTS
Section R9-22-712.75 - DRG Reimbursement: Payment for Administrative Days
Universal Citation: AZ Admin Code R 9-22-712.75
Current through Register Vol. 30, No. 38, September 20, 2024
A. Categories of Administrative Days. Administrative days fall into one of two categories, either (A)(1) or (A)(2).
1. Administrative days due to lack of
appropriate placement options and not meeting inpatient medical criteria.
Administrative days are days in which a member is admitted as an inpatient to
an acute care hospital, does not meet the criteria for an acute inpa-tient
stay, but is admitted or not discharged because;
(1) an appropriate placement outside the
hospital is not available,
(2) the
member cannot be safely discharged or transferred, or
(3) the Administration or the contractor
failed to provide for the appropriate placement outside the hospital in a
timely manner.
a. Administrative days may occur prior to an acute
care episode, for example, when a woman with a high-risk pregnancy is admitted
to a hospital while awaiting delivery.
b. Administrative days
may also occur at the end of an acute care episode, for example, when a member
is not discharged while awaiting placement in a nursing facility or other
sub-acute or post-acute setting.
c. Administrative days
may also include days in a receiving hospital when the member has been
discharged from one acute care hospital for the purpose of receiving sub-acute
services at the receiving hospital.
d
. Administrative days do not include days
when the member is awaiting appropriate placement or services that are
currently available but the hospital has not transferred or discharged the
member because of the hospital's administrative or operational
delays.
e. Administrative days
include inpatient claims covered by a RBHA or TRBHA that otherwise meet the
criteria in subsection (A)(1). 2. Administrative days for claims with the
principal diagnosis of behavioral health meeting inpatient medical criteria.
Administrative days are days with dates of discharge on or after October 1,
2018, in which a member is admitted as an inpatient to an acute care hospital,
meets the criteria for an acute inpatient stay, and the principal diagnosis on
the hospital claim is a behavioral health diagnosis. Inpatient claims covered
by a RBHA or TRBHA are not considered administrative days under subsection
(A)(2) regardless of the principal diagnosis on the hospital
claim.
B. Reimbursement of Administrative Days.
1. Administrative days under subsection
(A)(1) are reimbursed at the rate the claim would have paid had the services
not been provided in an inpatient hospital setting but had been provided at the
appropriate level of care such as the rate paid for stays at a nursing
facility.
2. Administrative days
under subsection (A)(2) are reimbursed at the daily rate found on the Inpatient
Behavioral Health Capped Fee-For-Service Schedule meeting the criteria of
"Service Description - Psychiatric Stay," regardless of revenue code.
C. Prior authorization is required for administrative days.
D. A hospital shall submit a claim for administrative days separate from any claim for reimbursement for the inpatient stay otherwise reimbursable under the DRG payment methodology.
Disclaimer: These regulations may not be the most recent version. Arizona may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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