California Code of Regulations
Title 8 - Industrial Relations
Division 1 - Department of Industrial Relations
Chapter 4.5 - Division of Workers' Compensation
Subchapter 1 - Administrative Director-Administrative Rules
Article 5.3 - Official Medical Fee Schedule
Section 9789.22 - Payment of Inpatient Hospital Services

(a) Unless otherwise provided by applicable provisions of this fee schedule, the maximum payment for inpatient medical services shall be determined by multiplying 1.20 by the product of the hospital's composite factor and the applicable DRG weight and by making any adjustments required by this fee schedule. The fee determined under this subdivision shall be a global fee, constituting the maximum reimbursement to a hospital for inpatient medical services not exempted under this section. However, preadmission services rendered by a hospital more than 24 hours before admission are separately reimbursable.

(b) The maximum payment for inpatient medical services includes reimbursement for all of the inpatient operating costs specified in Title 42, Code of Federal Regulations, Section 412.2(c), which is incorporated by reference and will be made available upon request to the Administrative Director, and the inpatient capital-related costs specified in Title 42, Code of Federal Regulations, Section 412.2(d), which is incorporated by reference and will be made available upon request to the Administrative Director. See Section 9789.25(a) for the Code of Federal Regulations reference for the effective date, revisions, and amendments by date of discharge.

(c) The maximum payment shall include the cost items specified in Title 42, Code of Federal Regulations, Section 412.2(e)(1), (2), (3), and (5), which in incorporated by reference and will be made available upon request to the Administrative Director. The maximum allowable fees for cost item set forth at 42 C.F.R. Section 412.2(e)(4), "the acquisition costs of hearts, kidneys, livers, lungs, pancreas, and intestines (or multivisceral organ) incurred by approved transplantation centers," shall be based on the documented paid cost of procuring the organ or tissue. See Section 9789.25(a) for the Code of Federal Regulations reference for the effective date, revisions, and amendments by date of discharge.

(d) The maximum payment shall cover all items and services provided to hospital inpatients other than professional services provided by physicians and other practitioners that are payable under the Official Medical Fee Schedule -- physicians fee schedule section in effect at the time the service was rendered (see Section 9789.111(a)). Except for services paid under the physicians fee schedule, all billing for payments shall originate from hospitals and payment may be made only to hospitals for the covered items and services, including any spinal device separately payable under Sections 9789.22(g).

(e) Hospitals billing for fees under this section shall be submitted in accordance with the e-billing regulations beginning with Section 9792.5.0 or the standardized paper billing regulations beginning with Section 9792.5.2.

(f)

(g) Additional allowance for spinal devices used in complex spinal surgery:

(h) "New technology pass-through": Additional payments will be allowed for new medical services and technologies as provided by CMS and set forth in Title 42, Code of Federal Regulations Section 412.87 and Section 412.88 which document is hereby incorporated by reference and will be made available upon request to the Administrative Director. See Section 9789.25(a) for the Code of Federal Regulations reference for the effective date, revisions, and amendments by date of discharge.

(i) Sole Community Hospitals: If a hospital meets the criteria for sole community hospitals, under Title 42, Code of Federal Regulations §412.92(a), and has been classified by CMS as a sole community hospital, its payment rates are determined under Title 42, Code of Federal Regulations §412.92(d), which document is hereby incorporated by reference and will be made available upon request to the Administrative Director. See Section 9789.25(a) for the Code of Federal Regulations reference for the effective date, revisions, and amendments by date of discharge.

(j) Transfers

(k) The following are exempt from the maximum reimbursement formula set forth in Section 9789.22(a) and are paid on a reasonable cost basis.

(l) For discharges occurring before January 1, 2013, a hospital that is not listed on the Medicare Cost Report should notify the Administrative Director and provide in writing the following information: OSHPD Licensure number, Medicare provider number, physical location, number of beds, and, if applicable, avearage FTE residents in approved training programs. If a hospital has been in operation for more than one year, information should also be provided on the precentage of inpatient days attributable to Medicaid patients.

For discharges occurring on or after January 1, 2013, a hospital that is not listed in Section 9789.23, may notify the Administrative Director and provide in writing the following Medicare information: Medicare provider number, physical location, county code, hospital specific operating and capital CCRs, and DSH and/or IME adjustments, if applicable.

(m) Any hospital that believes its composite factor or hospital specific outlier factor was erroneously determined because of an error in tabulating data may request the Administrative Director for a re-determination of its composite factor or hospital specific outlier factor. Such requests shall be in writing, shall state the alleged error, and shall be supported by written documentation. Within 30 days after receiving a complete written request, the Administrative Director shall make a redetermination of the composite factor or hospital specific outlier factor or reaffirm the published factor.