Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-3A-2

Definitions

Notice of Proposed Rule

(Amendment)

DAR File No.: 35207
Filed: 09/01/2011 09:05:51 AM

RULE ANALYSIS

Purpose of the rule or reason for the change:

The purpose of this change is to clarify that the Department uses Medicare's payment methodology for outpatient hospital services.

Summary of the rule or change:

This amendment removes language that defines outpatient hospital services to be less than 24 hours and clarifies that these services are defined by Medicare's payment methodology.

State statutory or constitutional authorization for this rule:

• 42 CFR 440.20
• Section 26-1-5
• Section 26-18-3

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because this change only clarifies that the Department uses Medicare's payment methodology for outpatient hospital services.

local governments:

There is no impact to local governments because they do not fund or provide outpatient hospital services to Medicaid recipients.

small businesses:

There is no impact to small businesses because this change only clarifies that the Department uses Medicare's payment methodology for outpatient hospital services.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid providers and to Medicaid recipients because this change only clarifies that the Department uses Medicare's payment methodology for outpatient hospital services.

Compliance costs for affected persons:

There is no impact to a single Medicaid provider or to a Medicaid recipient because this change only clarifies that the Department uses Medicare's payment methodology for outpatient hospital services.

Comments by the department head on the fiscal impact the rule may have on businesses:

Use of Medicare payment methodology for outpatient hospital services should provide standardization in the marketplace and be positive for providers.

David Patton, PhD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Health
Health Care Financing, Coverage and Reimbursement Policy
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

10/17/2011

This rule may become effective on:

10/24/2011

Authorized by:

David Patton, Executive Director

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-3A. Outpatient Hospital Services.

R414-3A-2. Definitions.

(1) "Allowed charges" mean actual charges submitted by the provider less any charges for non-covered services.

(2) "CHEC" means Child Health Evaluation and Care and is the Utah specific term for the federally mandated program of Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) for children under the age of 21.

(3) "Clinical Laboratory Improvements Act" (CLIA) is the Centers for Medicare and Medicaid Services (CMS) program that limits reimbursement for laboratory services based on the equipment and capability of the physician or laboratory to provide an appropriate, competent level of laboratory service.

(4) "Hyperbaric Oxygen Therapy" is therapy that places the patient in an enclosed pressure chamber for medical treatment.

(5) "Other Practitioner of the Healing Arts" means a doctor of dental surgery or a podiatrist.

(6) "Outpatient" is defined in 42 CFR 440.20[means professional services provided for less than a 24-hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the facility past midnight].

(7) "Prepaid Mental Health Plan" means the prepaid, capitated program through which the Department pays contracted community mental health centers to provide all needed inpatient and outpatient mental health services to residents of the community mental health center's catchment area who are enrolled in the plan.

 

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [September 1, ]2011

Notice of Continuation: November 8, 2007

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-2.3; 26-18-3(2); 26-18-4