TMPPM 2008 > Texas Medicaid Services > Military Hospital > Reimbursement

33.2 Reimbursement

Reimbursement is limited to claims submitted for emergency inpatient care only.

Allowed inpatient hospital stays are reimbursed according to a prospective payment methodology based on diagnosis-related groups (DRGs). The reimbursement method itself does not affect inpatient benefits and limitations. The Texas Medicaid Program requires that one claim be submitted for each inpatient stay with appropriate diagnosis and procedure code sequencing. Providers should submit only one claim per inpatient stay to Medicaid, regardless of the diagnosis, to ensure accurate payment. The DRG reimbursement includes all facility services that were provided to the client while registered as an inpatient.

Reimbursement to hospitals for inpatient services is limited to $200,000 per client, per benefit year (November 1 through October 31). This limitation does not apply to services related to certain organ transplants, services to clients younger than 21 years of age and covered by the Comprehensive Care Program (CCP), or to services for certain clients enrolled in Medicaid Managed Care.

Military hospitals should keep a Medicaid client as an inpatient only for the length of time necessary to stabilize that client. The Medicaid client, once stabilized, should be transferred to the nearest Medicaid acute care hospital facility for further treatment.

When more than one hospital provides care for the same client, the hospital that furnishes the most significant amount of care receives consideration for a full DRG payment.

The other hospital is paid a per diem rate based on the lesser of the mean length of stay for the DRG or eligible days in the facility. The DRG modifier PT on the Remittance and Status (R&S) report indicates per diem pricing related to a client transfer.

Client transfers within the same facility are considered one continuous stay and receive only one DRG payment. Medicaid does not recognize specialty units as separate entities; therefore, these transfers should be billed as one admission under the provider identifier. Admissions billed inappropriately are identified and denied during the utilization review process and may result in intensified review.

After all hospital claims have been submitted, TMHP performs a post-payment review to determine if the hospital furnishing the most significant amount of care received the full DRG. If the review reveals that the hospital furnishing the most significant amount of care did not receive the full DRG, an adjustment is initiated.

The inpatient DRG reimbursement includes payment for all radiology and laboratory services, including those sent to referral laboratories.

Refer to: "Reimbursement" for more information about reimbursement.

"THSteps-Comprehensive Care Program (CCP)" .