Out of State Medicaid FFS Claims Payment Calculations
- DOH Out of State Medicaid FFS Claims Payment Calculations (XLS, 42KB). Also available in PDF Format (PDF 33KB 6PG)
INLIER
Line | Calculation Elements | Traditional Medicaid Fee For Service (Out-of-State) |
---|---|---|
INLIER PAYMENT: | Data Source and Formulas | |
CALCULATION OF INLIER PAYMENT: | ||
1. | Discharge Case Payment Rate (Without IME for Medicaid Managed Care) | OOS_MA_FFS_Acute_Rate Code 2953_Col 1 |
2. | Per Case Service Intensity Weight for DRG Classification | SIW APR-DRG Table (DOH*) |
3. | Case Mix Adjusted Discharge Payment | Line 1 × Line 2 |
4. | Direct Medical Education (DME) Add-On | OOS_MA_FFS_Acute_Rate Code 2589_Col 3 |
5. | Capital per Discharge Rates (plus non-comparable add-ons where applicable) | OOS_MA_FFS_Acute_Rate Code 2990_Col 6 |
6. | Inlier DRG Payment | Line 3 + Line 4 + Line 5 |
ALTERNATE LEVEL OF CARE (ALC) PAYMENT: | ||
7. | CALCULATION OF ALC PAYMENT: | |
(a) | Alternate Level of Care (ALC) Price Per Day | OOS_MA_FFS_Acute_Rate Code 2950, 2951_Col 4, Col 5 |
(b) | Alternate Level of Care (ALC) Days | Medical Record |
(c) | Total ALC Payment | Line 7a × Line 7b |
TOTAL PAYMENT AMOUNT: | ||
8. | Total Inlier with ALC Payment at 100% | Line 6 + Line 7c |
MEDICAID SURCHARGE CALCULATION: | ||
A | Medicaid Surcharge (Indigent Care and Health Care Initiative Surcharge) | 4/1/09 Forward ==> 7.04% |
B | Medicaid Surcharge Amount | Line 8 × Line A |
C | Payment to Hospital if Provider Signed Authorization for Medicaid Direct Payment of Surcharge to the Pool Administrator. | Line 8 |
D | Payment to Hospital if Provider Did Not Sign Authorization for Medicaid Direct Payments - Hospital Pays Surcharge to the Pool Administrator. | Line 8 + Line B |
∗The SIW APR-DRG Table is available on the DOH public website at: http://www.nyhealth.gov/facilities/hospital/reimbursement/apr-drg/weights/
TRANSFER
Total Transfer Payment cannot exceed the amount that would have been paid if the patient had been discharged (Inlier) | ||
---|---|---|
Line | Calculation Elements | Traditional Medicaid Fee For Service (Out-of-State) |
TRANSFER DATA: | Data Source and Formulas | |
1. | TRANSFER DAYS DETERMINATION: | |
(a) | Total Number of Days in Stay (inc. ALC) | Medical Record |
(b) | Alternate Level of Care (ALC) Days | Medical Record |
(c) | Number of Days excluding ALC | Line 1a − 1b |
2. | Is this Case a Transfer? | Your Hospital Data |
o not use this methodology for patients assigned to a DRG specifically designated as a DRG for transfer patient only [i.e., neonate transferred < 5 days (DRGs 580 & 581)]. | ||
CALCULATION OF TRANSFER PAYMENT: | ||
3. | Discharge Case Payment Rate | OOS_MA_FFS_Acute_Rate Code 2953_Col 1 |
4. | Per Case Service Intensity Weight for DRG Classification | SIW APR-DRG Table (DOH*) |
5. | Case Mix Adjusted Discharge Payment | Line 3 × Line 4 |
6. | Statewide Average Arithmetic Inlier LOS for DRG | SIW APR-DRG Table (DOH*) |
7. | Average Inlier Cost Per Day | Line 5 ÷ Line 6 |
8. | TRANSFER ADJUSTMENT FACTOR: | |
(a) (b) |
If Statewide Average Arithmetic Inlier LOS for the DRG = 1, then Transfer Adj. Factor is 100% OR If Group Average Arithmetic Inlier LOS for the DRG > 1, then Transfer Adj. Factor is 120% |
100% or 120% |
9. | Transfer DRG Cost Per Day | Line 7 × Line 8a (or 8b) |
10. | Case Payment Capital per Diem | OOS_MA_FFS_Acute_Rate Code 2991_Col 7 |
11. | Total Transfer Cost Per Diem | Line 9 + Line 10 |
TRANSFER PAYMENT: | Data Source and Formulas | |
12. | Transfer Payment Amount excluding DME | Line 11 × Line 1c |
13. | Direct Medical Education (DME) Add-On | OOS_MA_FFS_Acute_Rate Code 2589_Col 3 |
14. | Transfer Payment Amount Before ALC | Line 12 + Line 13 |
15. | Discharge DRG Test: | |
(a) | Inlier DRG Before ALC | Inlier Tab, Line 6 |
16. | Total Transfer Payment Before ALC | Lesser of Line 14 or Line 15a |
17. | Total ALC Payment | Inlier Tab, Line 7c |
18. | Total Transfer with ALC Payment at 100% | Line 16 + Line 17 |
MEDICAID SURCHARGE CALCULATION: | Data Source and Formulas | |
A | Medicaid Surcharge (Indigent Care and Health Care Initiative Surcharge) | 4/1/09 Forward ==> 7.04% |
B | Medicaid Surcharge Amount | Line 18 × Line A |
C | Payment to Hospital if Provider Signed Authorization for Medicaid Direct Payment of Surcharge to the Pool Administrator. | Line 18 |
D | Payment to Hospital if Provider Did Not Sign Authorization for Medicaid Direct Payments - Hospital Pays Surcharge to Pool Administrator. | Line 18 + Line B |
∗The SIW APR-DRG Table is available on the DOH public website at: http://www.nyhealth.gov/facilities/hospital/reimbursement/apr-drg/weights/
HIGH COST
HIGH COST OUTLIER PAYMENT IS IN ADDITION TO INLIER PAYMENT CALCULATED ON THE INLIER WORKSHEET TAB. | ||
---|---|---|
Line | Calculation Elements | Traditional Medicaid Fee For Service (Out-of-State) |
HIGH COST OUTLIER PAYMENT: | Data Source and Formulas | |
1. | Total Inpatient Gross Charges Per Patient UB-92, HCFA 1450 | Charge Master |
2. | Adjustment to Total Inpatient Gross Charges: | |
a. | Telephone and Telegraph | Charge Master |
b. | Television and Radio | Charge Master |
c. | Private Room Differential | Charge Master |
d. | Other Non-Covered | Charge Master |
e. | Gross Charges for all ALC Days | Charge Master |
f. | Total Adjustments | Sum of Lines 2a thru 2e |
3. | Net Inpatient Gross Charges | Line 1 − Line 2f |
4. | High Cost Charge Converter | OOS_MA_FFS_Acute_Rate Code 2953_Col 9 |
5. | Net Inpatient Gross Charges Converted to Costs | Line 3 × Line 4 |
6. | Threshold Calculation: | |
a. | APR-DRG Cost Outlier Threshold | Outlier Threshold Table (DOH*) |
b. | Institution-Specific Adjustment Factor (ISAF/WEF) | OOS_MA_FFS_Acute_Rate Code 2953_Col 8 |
c. | Adjusted Cost Outlier Threshold | Line 6a × Line 6b |
7. | High Cost Payment Test: | |
a. | Do costs exceed the threshold? | Is Line 5 > 6c? |
b. | Does the case involve a Transfer? | Determination per Your Hospital Data |
CONTINUE WITH CALCULATION IF LINE 7a= "Yes" AND THE CASE IS NOT A TRANSFER. | ||
[High Cost Outlier does not apply to Transfer Cases (other than patients assigned to transfer DRGs) per 86-1.21.] | ||
HIGH COST OUTLIER PAYMENT: | Data Source and Formulas | |
8. | High Cost Outlier Payment before Inlier and ALC (100% of costs above adjusted threshold) | Line 5 − Line 6c |
9. | Total Inlier with ALC Payment at 100% | Inlier Worksheet Tab, Line 8 |
10. | Total Payment to Provider at 100% | Line 8 + Line 9 |
MEDICAID SURCHARGE CALCULATION: | Data Source and Formulas | |
A | Medicaid Surcharge (Indigent Care and Health Care Initiative Surcharge) | 4/1/09 Forward ==> 7.04% |
B | Medicaid Surcharge Amount | Line 10 × Line A |
C | Payment to Hospital if Provider Signed Authorization for Medicaid Direct Payment of Surcharge to the Pool Administrator. | Line 10 |
D | Payment to Hospital if Provider Did Not Sign Authorization for Medicaid Direct Payments - Hospital Pays Surcharge to Pool Administrator. | Line 10 + Line B |
∗The SIW APR-DRG Table is available on the DOH public website at: http://www.health.ny.gov/facilities/hospital/reimbursement/apr-drg/tresholds/