67:16:03:06.17.  Basis of reimbursement – Inpatient services – Claims containing revenue code 275 or 278. Claims submitted for inpatient hospital services by an in-state acute care hospital that had more than 30 Medicaid discharges during the hospital's fiscal year ending after June 30, 1996, and before July 1, 1997, that are considered to be cost outlier claims as defined by 67:16:03:01(3) and contain revenue code 275 or 278 from the National Uniform Billing Committee Official UB-04 Data Specifications Manual shall be reimbursed according to the following guidelines:

          (1)  Reimbursement for aggregate charges in excess of $5,000 associated with revenue code 275 or 278 is limited to the provider's actual cost plus 10 percent; and

          (2)  Aggregate charges for revenue code 275 or 278 in excess of $5,000 shall be removed from the calculation of the claim, and charges associated with the remainder of the claim shall be reimbursed according to § 67:16:03:06.

          The provider shall furnish a copy of the supplier's invoice for items associated with revenue code 275 and 278.

          Source: 38 SDR 224, effective July 1, 2012.

          General Authority: SDCL 28-6-1(2), 28-6-1.1.

          Law Implemented: SDCL 28-6-1(2), 28-6-1.1.

          Reference: National Uniform Billing Committee Official UB-04 Data Specifications Manual, 2012 Edition, page 116, published by the American Hospital Association. Copies may be obtained from the American Hospital Association, 155 North Wacker Drive, Chicago, Illinois 60606. Cost: $150.