Rule 67:16:03:06.01 Basis of reimbursement -- Outpatient services other than outpatient laboratory and outpatient surgical procedures.
67:16:03:06.01. Basis of reimbursement --
Outpatient services other than outpatient laboratory and outpatient surgical
procedures. Reimbursement for outpatient hospital services for an
in-state acute care hospital that had more than 30 inpatient Medicaid
discharges in the hospital's fiscal year ending after June 30, 1996, and before
July 1, 1997, is based on reasonable costs as determined by the hospital's
Medicare Cost Report from fiscal year 2010 with the following exceptions:
associated with the certified registered nurse anesthetist services that relate
to outpatient services are included as allowable costs; and
capital and education costs incurred for outpatient services will be included
as allowable costs.
for outpatient hospital services for the remaining in-state acute care
hospitals is at 90 percent of their usual and customary charge for the service
for out-of-state hospital outpatient services is calculated at 33.07 percent of
their usual and customary charge.
outpatient services incurred within three days immediately preceding the
inpatient stay are included in the inpatient charges unless the outpatient
service is not related to the inpatient stay. This provision applies only if
the facilities providing the services are owned by the entity.
laboratory services are excluded from the provisions of this rule and are
payable according to § 67:16:03:06.07.
surgical procedures are payable according to § 67:16:03:06.11.
The amount of
reimbursement calculated above is reduced by 11.48 percent after any cost
sharing amount due from the patient and any third party liability amounts have
been deducted and then increased by 0.5 percent for in-state hospitals that are
not classified as Medicare Critical Access or Medicaid Access Critical.
Hospitals that are classified as Medicare Critical Access or Medicaid Access
Critical are exempt from the 11.48 percent reduction in reimbursement. The rate
of reimbursement is increased by 1.8 percent for in-state hospitals that are
classified as Medicare Critical Access or Medicaid Access Critical.
costs for Medicaid Access Critical facilities the department uses the
facility's cost report to determine whether any adjustment to reimbursement is
necessary for amounts due the provider.
Source: 12 SDR 6, effective July 28, 1985;
15 SDR 2, effective July 17, 1988; 16 SDR 235, effective July 5, 1990; 17 SDR
180, effective May 27, 1991; 18 SDR 198, effective June 3, 1992; 22 SDR 143,
effective May 9, 1996; 23 SDR 232, effective July 10, 1997; 25 SDR 116,
effective March 24, 1999; 30 SDR 26, effective September 3, 2003; 31 SDR 107,
effective February 1, 2005; 36 SDR 215, effective July 1, 2010; 36 SDR 215, adopted
June 11, 2010, effective July 1, 2011; 37 SDR 236, effective June 28, 2011; 37
SDR 236, adopted June 8, 2011, effective July 1, 2012; 39 SDR 15, effective
August 6, 2012.
General Authority: SDCL 28-6-1.
Law Implemented: SDCL 28-6-1.
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