Hawaii Administrative Rules
Title 17 - DEPARTMENT OF HUMAN SERVICES
Department of Human Services
Chapter 1739 - AUTHORIZATION, PAYMENT, AND CLAIMS IN THE FEE-FOR-SERVICE MEDICAL ASSISTANCE PROGRAM
Subchapter 3 - PROSPECTIVE PAYMENT FOR ACUTE CARE SERVICES
Section 17-1739-61 - Preparation of data for calculation of base year prospective payment rates
Universal Citation: HI Admin Rules 17-1739-61
Current through February, 2024
(a) The department shall prepare data for the calculation of base year rates using the following general methodology.
(b) Base year claim charge data shall be prepared in order to establish charge ratios used in the payment calculation:
(1) Claim charge data
for all Medicare cross-over claims shall be considered based on dates of
discharge which correspond to each facility's fiscal year end;
(2) If more than one year of claim charge
data is used, the charges reflected on the earlier year's claims data shall be
inflated to the period covered by the most recent year's claims data in
accordance with section 17-1739-57(c);
(3) Claims shall be edited and properly
classified;
(4) Claim charge data
including charge amounts, days of care, and number of discharges, shall be
classified into the four service categories identified in section 17-1739-59.
Combined claims for the delivery of a normal newborn shall be counted as one
discharge in the calculation process. Claims for newborns described in section
17-1739-66(a)(5) shall be classified into the appropriate service
category;
(5) Claim charge data for
surgical, maternity, and medical claims in classifications II and III
facilities shall be segregated into routine, special care, and ancillary
service charges. Nursery charges shall be included in the routine
charges;
(6) Claim charge data
shall be adjusted in the case of classifications II and III facilities to
delete nonpsychiatric ancillary claim charges associated with claims in excess
of $35,000; and
(7) Claim charge
data shall be adjusted to delete ancillary charges for wait listed
patients.
(c) Cost report data including costs, days, and discharges, shall be extracted from base year cost reports and shall be prepared in order to determine medicaid allowable inpatient facility costs:
(1) Costs
of services excluded under section 17-1739-56 shall be deleted from costs for
purposes of the prospective rate calculation. This process shall involve
identifying items pertaining to the excluded services and subtracting these
costs from the cost report data;
(2) Costs in excess of federal Medicare cost
reimbursement limitations shall be deleted from costs for purposes of the
prospective rate calculation. Costs which are not otherwise specifically
addressed in this subchapter shall be included in a base year if they comply
with HCFA publication number HIM 15 standards. Capital costs associated with
the re-valuation of assets for any reason or due to a change in ownership,
operator, or leaseholder where such revaluation occurred after July 18, 1984
shall be identified and excluded. Costs in excess of charges shall not be
deleted from costs for the purpose of the prospective rate
calculation;
(3) Allowable medicaid
inpatient facility costs shall be determined separately for routine and
ancillary costs. Nursery costs shall be combined with other routine costs and
reclassified into the routine service component;
(4) The medicaid inpatient portion of
malpractice costs shall be determined by multiplying the ratio of medicaid
inpatient costs to total costs by the facility's total malpractice costs. This
amount shall be added to allowable medicaid inpatient facility costs;
(5) To recognize cost differences due to
varying fiscal year ends and annual inflationary increases, allowable medicaid
inpatient facility costs shall be standardized and inflated as described in
section 17-1739-68;
(6) Capital,
medical education, and for proprietary facilities, return on equity and gross
excise tax amounts shall be deleted from allowable medicaid inpatient facility
costs and shall be reimbursed in accordance with section 17-1739-65;
(7) Except as provided in section 17-1739-59,
services provided to patients during an inpatient stay but billed by a provider
other than the inpatient facility shall be added to allowable medicaid
inpatient facility costs. To obtain the estimated amount, the department shall
survey facilities and accept reasonable estimates of such services;
and
(8) In computing the
nonpsychiatric ancillary per discharge rates, the total ancillary costs and
discharges associated with nonpsychiatric outlier claims and ancillary costs
associated with wait listed patients shall be deleted from allowable medicaid
inpatient facility costs and discharges based on the claim charge ratios
identified in subsection (b) above. Routine costs and days related to the
outlier claims shall be included in inpatient costs and days extracted from the
cost reports and used in computation of the prospective payment rates. Routine
costs and days related to wait listed patients shall not be extracted from the
cost reports and shall be excluded from the computation of the inpatient
rates.
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