N.J. Admin. Code § 10:52-4.2

Current through Register Vol. 56, No. 11, June 3, 2024

Section 10:52-4.2 - Basis of payment; special hospitals (Classification A and B), private and governmental psychiatric hospitals and distinct (excluded units) of acute general hospitals-inpatient services

(a) The Division will reimburse special hospitals (Classification A) (acute and short term special hospitals) and Classification B (Rehabilitation hospitals), excluding specialized pediatric facilities licensed to provide pediatric comprehensive rehabilitation services, effective for the 2002 rate year, in accordance with P.L. 2001, c. 393, section 5, for inpatient services (including the interim and final settlement), in accordance with Medicare principles of reimbursement (see 42 CFR 413 ).

(b) Specialized pediatric facilities licensed to provide pediatric comprehensive rehabilitation services will be reimbursed a prospective per diem rate. The initial prospective per diem rate, effective for the 2002 rate year, shall be based on the total Medicaid inpatient costs divided by the total Medicaid days for Fiscal Year 1999, using the hospital's first finalized audited Fiscal Year 1999 cost report. If the hospital has been in operation less than two full years prior to Fiscal Year 1999, the prospective per diem rate shall be set using the hospital's first finalized audited Fiscal Year 2000 cost report. The initial prospective rate shall be increased annually by an economic factor, as specified in 10:52-5.13(a).

1. A hospital may request a change to its prospective per diem rate as either an adjustment to its base year costs in accordance with 42 CFR 413.40(g), or assignment of a new base year in accordance with 42 CFR 413.40(i).

2. The hospital's request shall be received within 180 days from the end of the fiscal year for which the adjustment or new base was requested, and shall include all supporting documentation.

3. The Division may grant an interim adjustment, subject to final adjudication of the hospital's request. The Division's final determination shall be made based upon financial data from the hospital's audited cost report for the year for which the adjustment or new base year was requested.

4. The Division shall issue a written determination with an explanation for each request for an adjustment or new base year.

5. If a hospital is not satisfied with the Division's determination, the hospital may request an administrative hearing pursuant to N.J.A.C. 10:49-10. If the hospital elects to request an administrative hearing, the request must be made within 20 calendar days from the date the Division's determination was received by the hospital. The Administrative Law Judge will review the reasonableness of the Division's reason for denying the requested rate adjustment based on the documentation that was presented to the Division. Additional evidence and documentation shall not be considered. The Director of the Division of Medical Assistance and Health Services shall thereafter issue the final agency decision, adopting, modifying or rejecting the Administrative Law Judge's initial decision. Thereafter, review may be sought in the Appellate Division.

(c) Prior authorization shall be required for patients with prognoses that necessitate lengths of stay in excess of 30 days. Reimbursable patient days shall be subject to utilization review requirements as specified in 10:52-1.15.

(d) The Medicaid/NJ FamilyCare program will reimburse special hospitals (Classification C) according to the rules and reimbursement methodology of N.J.A.C. 8:85, Long Term Care Services.

(e) The Division will reimburse private psychiatric hospitals and distinct units of acute general hospitals for inpatient services (including the interim and final settlement) in accordance with Medicare principles of reimbursement. Distinct units of acute general hospitals are not reimbursed through the Diagnosis Related Groups (DRG) reimbursement system for inpatient services in acute care general hospitals.

(f) Therapeutic leave days (days spent outside the facility) are not reimbursed to hospitals by the Division.

N.J. Admin. Code § 10:52-4.2

Amended by 50 N.J.R. 1261(a), effective 5/21/2018