Administrative Rules of Montana
Department 37 - PUBLIC HEALTH AND HUMAN SERVICES
Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES
Subchapter 37.86.29 - Inpatient Hospital Services
Rule 37.86.2916 - INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, COST OUTLIERS
Current through Register Vol. 6, March 22, 2024
(1) In addition to the APR-DRG payment, providers reimbursed under the APR-DRG prospective payment system may receive payment as provided in this rule for cost outliers for APR-DRGs.
(2) To receive payment for a cost outlier, the combined costs of the medically necessary days and services of the inpatient hospital stay, as determined by the department, must exceed the cost outlier threshold established by the department for the APR-DRG.
(3) The department determines the outlier reimbursement for cost outliers for all hospitals and distinct part units, entitled to receive cost outlier reimbursement, as follows:
AUTH: 2-4-201, 53-2-201, 53-6-113, MCA; IMP: 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA