Current through Register Vol. 49, No. 13, September 23, 2024
Subpart 1.
Scope of appeals.
A hospital may appeal a decision arising from the application
of standards or methods under Minnesota Statutes, section
256.9685,
256.9686, or
256.969, if an
appeal would result in a change to the hospital's payment rate or payments. The
appeals procedure in subparts
2 to
6 shall apply to all appeals
filed on or after August 1, 1989.
Subp.
2.
Filing of appeals.
An appeal must be received by the commissioner within the
time period specified in subpart
3,
4, or
5. The appeal must include
the information required in items A to D:
A. the disputed items;
B. the authority in federal or state statute
or rule upon which the hospital relies for each disputed item;
C. the type of appeal in subpart
3,
4, or
5 that is applicable to each
disputed item; and
D. the name and
address of the person to contact regarding the appeal.
Subp. 3.
Case mix appeals.
A hospital may appeal a payment change that results from a
difference in case mix between the base year and rate year. The appeal must be
received by the commissioner or postmarked no later than 120 days after the end
of the appealed rate year. A case mix appeal will apply to all medical
assistance patients who received inpatient hospital services from the hospital
for which the hospital received medical assistance payment excluding Medicare
crossovers and the appeal is effective for the entire rate year. A case mix
appeal excludes medical assistance admissions whose payments have been made
according to part
9500.1130, subpart 1b, item E. A
case mix appeal excludes medical assistance admissions that have a relative
value of zero for its DRG. The results of case mix appeals do not automatically
carry forward into later rate years. Separate case mix appeals must be
submitted for each rate year based on the change in the mix of cases for that
particular rate year. An adjustment will be made only to the extent that the
need is attributable to circumstances that are separately identified by the
hospital. The hospital must demonstrate that the average acuity or length of
stay of patients in each rate year appealed has increased or services have been
added or discontinued according to items A to J.
A. The change must be measured by use of case
mix indices derived using all DRG's. Relative values for each DRG will be
determined according to part
9500.1110, subpart
1, by substituting DRG terms
and data for diagnostic category terms and data. DRG relative values will be
determined based on all programs and the rehabilitation distinct part specialty
group. Separate DRG relative values will be determined for transfers to the
neonatal intensive care unit specialty group. For each program and specialty
group, make the determinations in subitems (1) to (6).
(1) Multiply the hospital's number of rate
year admissions within each DRG by the relative value of that DRG.
(2) Add together each of the products
determined in subitem (1).
(3)
Divide the total from subitem (2) by the hospital's number of rate year
admissions and round the quotient to five decimal places.
(4) Complete the functions in subitems (1) to
(3) for the hospital's base year admissions determined in part
9500.1110, subpart
1, item C.
(5) Divide the quotient determined in subitem
(3) by the quotient determined in subitem (4).
(6) Multiply subitem (5) by 100 and round the
percentage to five decimal places.
B. The percentage change, in whole numbers,
between the recalculated case mix indices under item A will be reduced by the
change in indices as measured using diagnostic categories in part
9500.1100, subparts 20b to 20g.
For each program and specialty group, make the determinations in subitems (1)
to (8).
(1) Multiply the hospital's number of
rate year admissions within each diagnostic category by the relative value of
that diagnostic category as determined in part
9500.1100.
(2) Add together each of the products
determined in subitem (1).
(3)
Divide the total from subitem (2) by the hospital's number of rate year
admissions and round the quotient to five decimal places.
(4) Complete the functions in subitems (1) to
(3) for the hospital's base year admissions determined in part
9500.1110, subpart
1, item C.
(5) Divide the quotient determined in subitem
(3) by the quotient determined in subitem (4).
(6) Multiply subitem (5) by 100 and round the
percentage to five decimal places.
(7) Divide item A, subitem (6), by subitem
(6).
(8) Multiply subitem (7) by
100 and round the percentage change to whole numbers.
C. Determine the payments made for admissions
occurring during the appealed rate year under part
9500.1128 reduced by property
payments made under parts
9500.1121,
9500.1122,
9500.1123, and
9500.1124 for each program and
specialty group.
D. Multiply item
B, subitem (8), by item C for each program and specialty group.
E. Subtract item C from item D for each
program and specialty group.
F. Add
the differences in item E.
G. Add
the differences in item C.
H.
Divide item F by item G. If the quotient is less than positive 0.05 and more
than negative 0.05, there can be no payment adjustment for a change in case
mix.
I. Subtract 0.05 from the
quotient in item H if the quotient is positive or add 0.05 if the quotient is
negative.
J. Multiply item G by
item I. If the product is positive, there is an underpayment with that amount
due the hospital. If the product is negative, there is an overpayment with that
amount due the department.
Subp.
4.
Medicare adjustment appeals.
To appeal a payment rate or payment change that results from
Medicare adjustments of base year information, the appeal must be received by
the commissioner or postmarked not later than 60 days after the date the
medical assistance determination was mailed to the hospital by the department
or within 60 days of the date the Medicare determination was mailed to the
hospital by Medicare, whichever is later.
Subp. 5.
Rate and payment
appeals.
To appeal a payment rate or payment determination that is not
a case mix or Medicare adjustment appeal, the appeal must be received by the
commissioner within 60 days of the date the determination was mailed to the
hospital.
Subp. 6.
Resolution of appeals.
The appeal will be heard by an administrative law judge
according to parts
1400.5100 to
1400.8401 and Minnesota Statutes,
sections
14.57
to
14.62, and
according to the requirements of items A to D.
A. The hospital must demonstrate by a
preponderance of the evidence that the commissioner's determination is
incorrect or not according to law.
B. Both overpayments and underpayments that
result from the submission of appeals will be implemented.
C. Facts to be considered in any appeal of
base year information are limited to those in existence at the time the payment
rates of the first rate year were established from the base year
information.
D. Relative values and
rates that are based on averages will not be recalculated to reflect the appeal
outcome.
