Okla. Admin. Code § 317:30-5-41 - Inpatient hospital coverage/limitations
(a) Covered hospital inpatient services are
those medically necessary services which require an inpatient stay ordinarily
furnished by a hospital for the care and treatment of inpatients and which are
provided under the direction of a physician or dentist in an institution
approved under OAC:317:30:5-40.1(a) or (b). Claims for inpatient admissions in
acute care or critical access hospitals are reimbursed the lesser of the billed
charges or the Diagnosis Related Groups (DRG) amount.
(b)
Inpatient status. OHCA
considers a member an inpatient when the member is admitted to the hospital and
is counted in the midnight census. In situations when a member inpatient
admission occurs and the member dies, is discharged following an obstetrical
stay, or is transferred to another facility on the day of admission, the member
is also considered an inpatient of the hospital.
(1)
Same day admission. If a
member is admitted and dies before the midnight census on the same day of
admission, the member is considered an inpatient.
(2)
Same day admission/discharge
obstetrical and newborn stays. A hospital stay is considered inpatient
stay when a member is admitted and delivers a baby, even when the mother and
baby are discharged on the date of admission (i.e., they are not included in
the midnight census). This rule applies when the mother and/or newborn are
transferred to another hospital.
(3)
Same day admission/discharges other
than obstetrical and newborn stays. In the event a member is admitted as
an inpatient, but is determined to not qualify for an inpatient payment based
on OHCA criteria, the hospital may bill on an outpatient claim for the
ancillary services provided during that time.
(4)
Discharges and Transfers. A
hospital inpatient is considered discharged from a hospital paid under the
DRG-based payment system when:
(A) The
patient is formally released from the hospital; or
(B) The patient dies in the hospital; or
(C) The patient is transferred to
a hospital that is excluded from the DRG-based payment system, or transferred
to a distinct part psychiatric or rehabilitation unit of the same hospital.
Such instances will result in two or more claims. Effective January 1, 2007,
distinct part psychiatric and rehabilitation units excluded from the Medicare
Prospective Payment System (PPS) of general medical surgical hospitals will
require a separate provider identification number.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(a) Covered hospital inpatient services are those medically necessary services which require an inpatient stay ordinarily furnished by a hospital for the care and treatment of inpatients and which are provided under the direction of a physician or dentist in an institution approved under OAC :317:30:5-40.1(a) or (b). Claims for inpatient admissions in acute care or critical access hospitals are reimbursed the lesser of the billed charges or the Diagnosis Related Groups (DRG) amount.
(b) Inpatient status. OHCA considers a member an inpatient when the member is admitted to the hospital and is counted in the midnight census. In situations when a member inpatient admission occurs and the member dies, is discharged following an obstetrical stay, or is transferred to another facility on the day of admission, the member is also considered an inpatient of the hospital.
(1) Same day admission. If a member is admitted and dies before the midnight census on the same day of admission, the member is considered an inpatient.
(2) Same day admission/discharge obstetrical and newborn stays. A hospital stay is considered inpatient stay when a member is admitted and delivers a baby, even when the mother and baby are discharged on the date of admission (i.e., they are not included in the midnight census). This rule applies when the mother and/or newborn are transferred to another hospital.
(3) Same day admission/discharges other than obstetrical and newborn stays. In the event a member is admitted as an inpatient, but is determined to not qualify for an inpatient payment based on OHCA criteria, the hospital may bill on an outpatient claim for the ancillary services provided during that time.
(4) Discharges and Transfers. A hospital inpatient is considered discharged from a hospital paid under the DRG-based payment system when:
(A) The patient is formally released from the hospital; or
(B) The patient dies in the hospital; or
(C) The patient is transferred to a hospital that is excluded from the DRG-based payment system, or transferred to a distinct part psychiatric or rehabilitation unit of the same hospital. Such instances will result in two or more claims. Effective January 1, 2007, distinct part psychiatric and rehabilitation units excluded from the Medicare Prospective Payment System (PPS) of general medical surgical hospitals will require a separate provider identification number.