New Mexico Administrative Code
Title 8 - SOCIAL SERVICES
Chapter 311 - HOSPITAL SERVICES
Part 3 - METHODS AND STANDARDS FOR ESTABLISHING PAYMENT - INPATIENT HOSPITAL SERVICES
Section 8.311.3.11 - PAYMENT METHODOLOGY FOR PPS- EXEMPT HOSPITALS AND EXEMPT UNITS WITHIN HOSPITALS
Universal Citation: 8 NM Admin Code 8.311.3.11
Current through Register Vol. 35, No. 18, September 24, 2024
A. Application of TEFRA principles of reimbursement:
(1) The principles and methods identified in
Public Law 97-248 provision (TEFRA), effective October 1, 1982, regarding
allowable payment for inpatient hospital services, and any subsequent changes
to such provision shall be used to determine:
(a) the amount payable by the department
through its fiscal agent for services covered under the MAD program and
provided to eligible recipients; and
(b) the manner of payment and the manner of
settlement or overpayments and underpayment for inpatient services provided by
hospitals for MAD reimbursement purposes, effective for all accounting periods
which begin on or after October 1, 1983.
(2) The inflation factor used in the
calculations will be identical to that used by medicare to update payments to
hospitals which are reimbursed using the TEFRA methodology, except for the
period October 9, 1991 through September 30, 1992, for which the inflation
factor will be .5 percent for urban hospitals and 1.5 percent for rural
hospitals.
(3) In accordance with
Section 1902 (s)(3) of the Social Security Act effective July 1, 1991, the
TEFRA rate of increase limit for inpatient hospital services will not apply to
the delivery of such services to any individual who has not attained their
first birthday, (or in the case of such an individual who is an inpatient on
his first birthday until such individual is discharged).
B. Appeals:
(1) Hospitals may appeal the target rate and
application of same, if circumstances beyond the hospitals' control have caused
the reimbursement rates to fall at least five percent below actual allowable
costs.
(2) Such appeals must be
filed in writing within 180 calendar days of the notice of final settlement and
must contain sufficient supporting documentation to demonstrate that the
circumstances causing the situation were not within the control of the hospital
and that the continued imposition of the target rate would cause a significant
financial hardship.
(3) The
department shall review the supporting documentation and, if appropriate, grant
an exemption from or modification of the target rate. The department's
determination on the merits of the appeal will be made within 180 calendar days
of receipt of the appeal request, although the state may make a determination
to extend such period to a specified date as necessary.
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