Utah Administrative Code
Topic - Health
Title R414 - Integrated Healthcare
Rule R414-2A - Inpatient Hospital Services
Section R414-2A-8 - Provider-Preventable Conditions
Universal Citation: UT Admin Code R 414-2A-8
Current through Bulletin 2024-06, March 15, 2024
(1) Medicaid does not pay for Provider Preventable Conditions (PPC).
(a) Medicaid utilizes the Medicaid
Severity-Diagnosis Related Group (MS-DRG) to identify a PPC.
(b) For inpatient hospital claims, Medicaid
does not cover PPCs in Medicare crossover patients.
(c) To qualify as a PPC, one of the
Medicare-listed diagnoses must develop during hospitalization.
(i) When present on admission, these
diagnoses are not considered to be a PPC for that hospitalization.
(ii) Providers are expected to identify
Present on Admission (POA) status for all diagnoses on each claim according to
correct coding standards.
(d) Providers must assure that all
PPC-related diagnoses, services, and charges are noted as "non-covered charges"
on the claim.
(i) The Department does not use
non-covered charges in calculating the hospital reimbursement.
(e) The Department shall deny
PPC-related claims that result in an outlier payment and medical records will
be required.
(i) Providers will receive
Remittance Advice (RA) that confirms the occurrence of a PPC outlier
claim.
(ii) The Department requires
providers to know which medical records and other required documents are
needed.
(iii) Upon RA notification
of a PPC, the provider shall submit the following documents within 30 days:
(A) "Outlier PPC Medical Record Documentation
Submission Form";
(B) Complete
medical records from the associated hospital stay;
(C) Itemized bill (tab de-limited text file
or Excel spreadsheet), including a detailed listing of PPC-related charges as
non-covered charges, with total charges matching the total charges submitted on
the claim.
(f) The Department will review and, if
appropriate, reprocess the claim based upon the review of the required
documents submitted within the 30-day period of RA notification.
(g) The Department shall deny review of the
claim unless the required documentation is submitted within 30 days of RA
notification.
(h) The Department
requires providers to report PPCs in accordance with Section
R414-1-28.
Disclaimer: These regulations may not be the most recent version. Utah may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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