N.M. Code R. § 8.311.3.11

Current through Register Vol. 35, No. 11, June 11, 2024

Section 8.311.3.11 - PAYMENT METHODOLOGY FOR PPS- EXEMPT HOSPITALS AND EXEMPT UNITS WITHIN HOSPITALS

A.Application of TEFRA principles of reimbursement:

(1) The principles and methods identified in Public Law 97-248 provision (TEFRA), effective October 1, 1982, regarding allowable payment for inpatient hospital services, and any subsequent changes to such provision shall be used to determine:

(a) the amount payable by the department through its fiscal agent for services covered under the MAD program and provided to eligible recipients; and

(b) the manner of payment and the manner of settlement or overpayments and underpayment for inpatient services provided by hospitals for MAD reimbursement purposes, effective for all accounting periods which begin on or after October 1, 1983.

(2) The inflation factor used in the calculations will be identical to that used by medicare to update payments to hospitals which are reimbursed using the TEFRA methodology, except for the period October 9, 1991 through September 30, 1992, for which the inflation factor will be .5 percent for urban hospitals and 1.5 percent for rural hospitals.

(3) In accordance with Section 1902 (s)(3) of the Social Security Act effective July 1, 1991, the TEFRA rate of increase limit for inpatient hospital services will not apply to the delivery of such services to any individual who has not attained their first birthday, (or in the case of such an individual who is an inpatient on his first birthday until such individual is discharged).

B.Appeals:

(1) Hospitals may appeal the target rate and application of same, if circumstances beyond the hospitals' control have caused the reimbursement rates to fall at least five percent below actual allowable costs.

(2) Such appeals must be filed in writing within 180 calendar days of the notice of final settlement and must contain sufficient supporting documentation to demonstrate that the circumstances causing the situation were not within the control of the hospital and that the continued imposition of the target rate would cause a significant financial hardship.

(3) The department shall review the supporting documentation and, if appropriate, grant an exemption from or modification of the target rate. The department's determination on the merits of the appeal will be made within 180 calendar days of receipt of the appeal request, although the state may make a determination to extend such period to a specified date as necessary.

N.M. Code R. § 8.311.3.11

2-1-95; 8.311.3.11 NMAC - Rn, 8 NMAC 4.MAD.721.D.II, 1-1-01; A, 4-1-11, Adopted by New Mexico Register, Volume XXVII, Issue 10, May 31, 2016, eff. 6/1/2016