Payments to Hospitals Sample Clauses
The "Payments to Hospitals" clause defines the terms and conditions under which payments are made to hospitals for services rendered. It typically outlines the payment schedule, methods of reimbursement, and any requirements for documentation or invoicing that hospitals must follow to receive payment. For example, it may specify that hospitals are paid within a certain number of days after submitting a valid claim or invoice. The core function of this clause is to ensure timely and accurate compensation for hospital services, thereby reducing disputes and providing financial clarity for both parties.
Payments to Hospitals. 5.17.1 Payments must be made to hospitals subject to the Hospital Safety Net Assessment in accord with Chapter 74.60 RCW as follows:
5.17.1.1 HCA will provide information to the Contractor to facilitate its payments to the hospitals subject to the Hospital Safety Net Assessment.
5.17.2 The Contractor will pay all hospitals at least the Inpatient and Outpatient rates published by HCA for its fee-for-service program.
5.17.3 Treatment of Inpatient Hospital Claims for Certified Public Expenditure (CPE) Hospitals.
5.17.3.1 Because HCA can leverage additional federal funds for fee-for-service inpatient claims at CPE facilities, these expenditures were carved out of the premium payments for the blind and disabled populations moved from fee-for-service (FFS) to Healthy Options beginning July 1, 2012. HCA will separately identify the enrollees subject to the carve- out. If an enrollee’s eligibility category changes to ABHD while he or she is an inpatient at a CPE hospital:
5.17.3.1.1 The Contractor is responsible for the claim when the AHBD eligibility does not cover the entire hospitalization.
5.17.3.1.2 HCA is responsible for the inpatient claim when the enrollee’s AHBD eligibility covers the entire hospitalization.
5.17.3.2 While premiums are net of CPE inpatient hospital claims, the Contractor does remain at risk for these fee-for-service claims if they exceed expectations. CPE inpatient hospital expenditure benchmarks will be computed on a per-member-per month (PMPM) basis, and will vary by category, age, gender and region.
5.17.3.3 After the end of each calendar year, HCA will compute aggregate CPE hospital FFS expenditures attributable to the Contractor, based upon actual enrollment. Actual CPE hospital expenditures for all Contractor enrolled member months will be compared to the Contractor specific benchmarks that take into account changes in utilization and risk. If actual expenditures exceed the established benchmarks, the Contractor will reimburse the State for the amount of the excess. The State will not make payments to any MCO if expenditures are below benchmark amounts.
5.17.3.4 The following is a list of CPE Hospitals: • University of Washington Medical Center • Harborview Medical Center • Cascade Valley Hospital • Evergreen Hospital and Medical Center • Kennewick General Hospital • Olympic Medical Center • Samaritan Hospital – Moses Lake • Skagit County Hospital District #2 – Island • Skagit Valley Hospital • Valley General Hospital – Monroe • Val...
Payments to Hospitals. 5.18.1 The Contractor will pay all hospitals for services delivered under the Inpatient and Outpatient service categories at rates no less than those published by HCA for its FFS program, including the Administrative Day rate which is applicable through the date of discharge, regardless of the level of service being provided.
5.18.2 Administrative Day Rate Criteria
5.18.2.1 The Contractor shall not impose additional criteria to that outlined in WAC 182-550-4550 to determine eligibility for Administrative Days, and shall provide payment to any hospital for allowable Medically Necessary Services performed during an Enrollee’s hospital stay for which the Contractor is the payor of the hospital stay, if the hospital stay meets the following requirements:
Payments to Hospitals. 5.17.1 Payments must be made to hospitals subject to the Hospital Safety Net Assessment in accord with Chapter 74.60 RCW as follows:
5.17.1.1 HCA will provide information to the Contractor to facilitate its payments to the hospitals subject to the Hospital Safety Net Assessment.
5.17.2 The Contractor will pay all hospitals for services delivered underat least the Inpatient and Outpatient service categories at rates no less than those published by HCA for its fee-for-service program, including the administrative day rate.
5.17.3 Potentially Preventable Readmissions. (WAC 182-550-3840).
5.17.3.1 Upon notice by HCA the Contractor shall ensure:
5.17.3.1.1 Contracts with hospitals include the HCA-assigned percentage reduction for future inpatient admissions based on the Navigant statistical readmission algorithm; and
Payments to Hospitals. The Contractor will pay all hospitals at least the Inpatient and Outpatient rates published by HCA for its fee-for-service program.