Rule 23-202-4.4 - ReimbursementA. All fee-for-service (FFS) transplants performed in the state of Mississippi are paid under the Mississippi All Patient Refined-Diagnosis Related Group (APR-DRG) payment methodology, including a policy adjustor.B. All FFS transplants available in Mississippi but performed outside the state of Mississippi are paid under the Mississippi APR-DRG payment methodology, including a policy adjustor.C. Payment for transplant services not available in Mississippi is made under the Mississippi APR-DRG payment methodology including a policy adjustor. If the Mississippi APR-DRG payment limits access to care, a case rate may be set. 1. A case rate is set at forty percent (40%) of the sum of billed charges for transplant services as published in the State Plan according to Milliman's U.S. Organ and Tissue Transplant Cost Estimates and Discussion in effect as of July 1, 2019.2. The Milliman categories comprising the sum of billed charges include outpatient services received thirty (30) days pre-transplant, procurement, hospital transplant inpatient admission, physician services during transplant and one-hundred eighty (180) days post (transplant) hospital discharge. Outpatient immunosuppressants and other prescriptions are not included in the case rate.3. If the transplant hospital stay exceeds the hospital length of stay published by Milliman, an outlier per-diem payment will be made for each day that exceeds the hospital length of stay.4. Reimbursement for transplant services cannot exceed one-hundred percent (100%) of the sum of Milliman's billed charges for the categories listed in Miss. Admin. Code Part 202, Rule 4.4.C.2.5. Provisions listed in Miss. Admin. Code Part 202, Rule 4.4 apply to transplant services on or after October 1, 2012.6. Transplant services not available in Mississippi and not listed in the Milliman's U.S. Organ and Tissue Transplant Cost Estimates and Discussion will be reimbursed using the Mississippi APR-DRG payment methodology. If the Mississippi APR-DRG payment limits access to care, the Division of Medicaid will reimburse what the domicile state pays for the service.D. All conditions of third party liability procedures must be satisfied.E. All claims must be submitted according to the requirements of the Mississippi Medicaid program.F. All charges, both facility and physician, relating to procurement/storage must be billed by the transplant facility on the current uniform billing (UB) claim form with the appropriate revenue code(s).G. The Division of Medicaid reimburses all facility and physician charges relating to the procurement of an organ, whether from a cadaver or a living donor, to the transplant facility using the appropriate revenue codes.23 Miss. Code. R. § 202-4.4
42 C.F.R. §§ 441.35, 482.90 - 104; Miss. Code Ann. §§ 43-13-117, 43-13-121.