REIMBURSEMENT FOR INPATIENT SERVICES. 1. DRG Reimbursement shall apply to each admission of a Member to Medical Services Entity’s facility unless another reimbursement methodology, such as, but not limited to, Stop Loss Reimbursement or Transfer Reimbursement (defined below), applies according to the terms of this Attachment.
2. DRG reimbursement is inclusive of all Covered Services furnished by Medical Services Entity and by non-physician providers while the Member is admitted to Medical Services Entity’s facility. The Covered Services furnished to the Member while admitted to Medical Services Entity’s facility shall be billed only by Medical Services Entity and not by any non-physician provider. Inpatient professional services furnished by physician providers (i.e., MDs, DOs), shall be billed separately.
3. Stop Loss Reimbursement shall apply to any admission of a Member to Medical Services Entity’s facility if the Stop Loss Threshold and any other preconditions to Stop Loss Reimbursement are met, such as, but not necessarily limited to, Medical Services Entity’s facility’s disproportionate share hospital status and the age of the Member.
a. If Medical Services Entity is a disproportionate share hospital, Stop Loss Reimbursement under this Attachment shall apply only to admissions of children under six years old at the time of admission (or such other age threshold determined by HSD) and when the Stop Loss Threshold has been met.
b. If Medical Services Entity is not a disproportionate share hospital, Stop Loss Reimbursement under this Attachment shall apply only to admission of children under one year old (or such other age threshold determined by HSD) at the time of admission and when the Stop Loss Threshold has been met.
c. For the avoidance of any doubt, when, pursuant to the foregoing, Stop Loss Reimbursement under this Attachment does not apply, Medical Services Entity’s reimbursement for inpatient services shall be determined by DRG Reimbursement, regardless of the amount of Billed Charges.
4. If the Member’s admission constitutes a Transfer Case, Corporation may review and reimburse the admission to Medical Services Entity’s facility according to HSD’s transfer payment methodology (“Transfer Reimbursement”) in lieu of DRG Reimbursement or Stop Loss Reimbursement.
5. Readmissions occurring within 15 calendar days of a prior acute care admission for a related condition may be reviewed to determine Medical Necessity and appropriateness of care. Corporation may review the appropriateness ...
