Okla. Admin. Code § 317:30-5-41

Current through Vol. 42, No. 3, October 15, 2024

Section 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 a physician writes an order for the member to be admitted to a participating hospital; the member is admitted and is receiving room, board, and professional services provided on a continuous twenty-four (24) hour a day basis; and a member is counted in the midnight census. A length of stay less than twenty-four (24) hours may be considered if the stay meets an inpatient acuity level of care. In situations when a member's 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 review, 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.

Okla. Admin. Code § 317:30-5-41

Added at 12 Ok Reg 751, eff 1-5-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3131, eff 7-27-95; Amended at 13 Ok Reg 3607, eff 6-18-96 (emergency); Amended at 13 Ok Reg 3585, eff 7-16-96 through 7-16-96 (emergency); Amended at 14 Ok Reg 1208, eff 8-7-96 (emergency); Amended at 14 Ok Reg 3077, eff 7-1-97 (emergency); Amended at 15 Ok Reg 1528, eff 5-11-98; Amended at 15 Ok Reg 3784, eff 7-1-98 (emergency); Amended at 16 Ok Reg 1429, eff 5-27-99; Amended at 16 Ok Reg 3413, eff 7-1-99 (emergency); Amended at 17 Ok Reg 708, eff 1-10-00 (emergency); Amended at 17 Ok Reg 1204, eff 5-11-00; Amended at 17 Ok Reg 3469, eff 8-1-00 (emergency); Amended at 18 Ok Reg 477, eff 1-1-01 (emergency); Amended at 18 Ok Reg 761, eff 1-23-01 (emergency); Amended at 18 Ok Reg 1130, eff 5-11-01; Amended at 19 Ok Reg 2134, eff 6-27-2; Amended at 20 Ok Reg 2762, eff 7-1-03 (emergency); Amended at 21 Ok Reg 2176, eff 6-25-04; Amended at 23 Ok Reg 239, eff 10-3-05 (emergency); Amended at 23 Ok Reg 771, eff 3-9-06 (emergency); Amended at 23 Ok Reg 2440, eff 6-25-06; Amended at 24 Ok Reg 317, eff 12-1-06 (emergency); Amended at 24 Ok Reg 905, eff 5-11-07

Amended by Oklahoma Register, Volume 31, Issue 24, September 2, 2014, eff. 9/12/2014

Amended by Oklahome Register, Volume 33, Issue 23, August 15, 2016, eff. 9/1/2016

Amended by Oklahoma Register, Volume 41, Issue 23, August 15, 2024, eff. 9/1/2024