South Dakota Administrative Rules
Title 67 - Department of Social Services
Article 67:16 - Covered medical services
Chapter 67:16:03 - Hospital services
Section 67:16:03:06.01 - Basis of reimbursement - Outpatient services other than outpatient laboratory and outpatient surgical procedures
Current through Register Vol. 51, page 43, September 23, 2024
Reimbursement for all outpatient hospital services for Medicare prospective payment system hospitals will be paid using the Medicaid agencys outpatient prospective payment system (OPPS).
Reimbursement for remaining outpatient hospital services for an in-state acute care hospital that had more than 30 inpatient Medicaid discharges in the hospital's fiscal year ending after June 30, 1996, and before July 1, 1997, is adjusted annually for inflation as appropriated by the Legislature and is based on reasonable costs as determined by the hospital's Medicare Cost Report from fiscal year 2010 with the following exceptions:
(1) Costs associated with the certified registered nurse anesthetist services that relate to outpatient services are included as allowable costs; and
(2) All capital and education costs incurred for outpatient services will be included as allowable costs.
Reimbursement for outpatient hospital services for the remaining in-state acute care hospitals is at 90 percent of their usual and customary charge for the service provided.
Reimbursement for out-of-state hospital outpatient services is calculated at a percentage of their usual and customary charge as appropriated by the Legislature.
Costs for outpatient services incurred within three days immediately preceding the inpatient stay are included in the inpatient charges unless the outpatient service is not related to the inpatient stay. This provision applies only if the facilities providing the services are owned by the entity.
Except for Medicare prospective payment system hospitals, outpatient laboratory services are excluded from the provisions of this rule and are payable according to § 67:16:03:06.07.
Outpatient surgical procedures are payable according to § 67:16:03:06.11.
For outpatient costs for Medicaid Access Critical facilities the department uses the facility's cost report to determine whether any adjustment to reimbursement is necessary for amounts due the provider.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
South Dakota Medicaid State Plan, Attachment 4.19-B, page 1b. Copies may be obtained from the Department of Social Services, Division of Medical Services. 700 Governor's Drive, Pierre, South Dakota 57501.
