HOME    SEARCH    ABOUT US    CONTACT US    HELP   
           
This is an obsolete version of the rule. Please click on the rule number to view the current version.

37.86.2907    INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, APR-DRG PAYMENT RATE DETERMINATION

(1) The department's APR-DRG prospective payment rate for inpatient hospital services is based on the classification of inpatient hospital discharges to APR-DRGs. The procedure for determining the APR-DRG prospective payment rate is as follows:

(a) Effective October 1st of each year, the department will assign an APR-DRG to each Medicaid patient discharge in accordance with the current APR-grouper program version, as developed by 3M Health Information Systems. The assignment of each APR-DRG is based on:

(i) the ICD-9-CM principal diagnoses;

(ii) all ICD-9-CM secondary diagnoses;

(iii) all ICD-9-CM medical procedures performed during the recipient's hospital stay;

(iv) the recipient's age;

(v) the recipient's sex; and

(vi) the recipient's discharge status.

(b) For each APR-DRG, the department determines a relative weight using a national database from 3M that reflects the cost of hospital resources used to treat cases. The relative weights have been recentered so that the average Montana Medicaid stay has a base weight of 1.00. Adjustments are applied to specific APR-DRG weights to reflect department policy. The relative weight for each APR-DRG is available upon request from Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(c) The department computes a Montana average base price per case. Effective July 1, 2009 the average base price, including capital expenses, is $4,235. Disproportionate share payments are not included in this price.

(i) The average base price for Center of Excellence hospitals, including capital expenses, is $7,024. Disproportionate share payments are not included in this price.

(ii) The average base for distinct part rehabilitation units and long term care hospitals (LTCH), including capital expenses, is $9,092. Disproportionate share payments are not included in this price.

(d) The relative weight for the assigned APR-DRG is multiplied by the average base price per case to compute the APR-DRG prospective payment rate for that Medicaid patient discharge.

(2) The Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), and outlier thresholds are contained in the APR-DRG Table of Weights and Thresholds (effective October 1, 2008) published by the department. The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds (effective October 1, 2008). Copies may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

History: 2-4-201, 53-2-201, 53-6-113, MCA; IMP, 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA; NEW, 2004 MAR p. 482, Eff. 2/27/04; AMD, 2005 MAR p. 265, Eff. 2/11/05; AMD, 2006 MAR p. 768, Eff. 3/24/06; AMD, 2006 MAR p. 1640, Eff. 7/1/06; AMD, 2006 MAR p. 2849, Eff. 11/10/06; AMD, 2007 MAR p. 1680, Eff. 10/26/07; AMD, 2008 MAR p. 1983, Eff. 10/1/08; AMD, 2009 MAR p. 2029, Eff. 10/30/09.

Home  |   Search  |   About Us  |   Contact Us  |   Help  |   Disclaimer  |   Privacy & Security