Illinois Administrative Code
Title 89 - SOCIAL SERVICES
Part 149 - DIAGNOSIS RELATED GROUPING (DRG) PROSPECTIVE PAYMENT SYSTEM (PPS)
Section 149.105 - Payment For Outlier Cases
Current through Register Vol. 48, No. 12, March 22, 2024
Effective for dates of discharge on or after July 1, 2014:
a) Outlier adjustment determination. Except as provided in subsection (b), the Department may provide for additional payment, approximating a hospital's marginal cost of covered inpatient hospital services beyond thresholds specified by the Department. To qualify for the payment, the claim must meet the following criteria:
b) Estimated Claim Cost. Estimated claim cost is based on the product of the claim total covered charges and the hospital's Medicare IPPS outlier cost-to-charge ratio. The Medicare IPPS outlier cost-to-charge ratio is determined based on:
c) Exclusions. No outlier adjustment shall be paid on claims that are excluded from the DRG PPS pursuant to Section 149.50(b).
d) Outlier Adjustment Payment. The amount of the additional payment shall be determined as the product, rounded to the nearest hundredth, of:
e) Definitions
In addition to terms elsewhere defined in this subchapter, terms relating to outlier adjustments are defined as follows:
"Claim outlier threshold" means the sum of the DRG base payment, as defined in Section 149.100(d) and the fixed loss threshold.
"Fixed loss threshold" means the Medicare fixed loss threshold in effect on October 1, 2012. The Department is authorized to update the "fixed loss threshold". Base rates must be updated within 12 months after the update.
"MDC" means major diagnostic category.
"Medicare CBSA" means the Core-Based Statistical Areas for a hospital's location effective in the Medicare inpatient prospective payment system at the beginning of the federal fiscal year starting three months prior to the calendar year during which the discharge occurred.
SOI adjustment factor" means for SOI 1, 0.8000; for SOI 2, 0.8000; for SOI 3, 0.9500; for SOI 4, 0.9500.
"Total covered charges" means the amount entered for revenue code 001 in column 53 (Total Charges) on the Uniform Billing Form (form CMMS 1450), or one of its electronic transaction equivalents.