Policies & Guidelines
- Compliance
- Definitions
- Ambulatory Surgical Services
- Billing Policy
- Children's Services
- Chiropractic Services
- Clinic Services
- Dental
- HCBS Elderly Waiver
- Home Care
- Hospice
- Hospital Services
- Inpatient Hospital Notification and Authorization
- Laboratory/Pathology, Radiology and Diagnostic Services
- Long-Term Care
- Mental Health Services
- Optical Services
- Pharmacy Services
- Physician and Professional Services
- Rehabilitative Services
- Requirements for Providers
- Service Authorization
- Substance Use Disorder Services
- Transportation
- Tribal and Indian Health Services
- Legal References
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- Ambulatory Surgical Services
- Billing Policy
- CFSS
- Children's Services
- Chiropractic Services
- Clinic Services
- Dental
- Equipment and Supplies
- HCBS Elderly Waiver
- Home Care
- Hospice
- Hospital Services
- Housing Stabilization Services
- Immunizations and Vaccinations
- Inpatient Hospital Notification and Authorization
- Laboratory/Pathology, Radiology and Diagnostic Services
- Long-Term Care
- Member Eligibility
- Mental Health Services
- Optical Services
- Pharmacy Services
- Physician and Professional Services
- Recuperative Care
- Rehabilitative Services
- Requirements for Providers
- Service Authorization
- Substance Use Disorder Services
- Transportation
- Tribal and Indian Health Services
- Quality: HEDIS
- Policies & Procedures
Hospital Services
Definitions
Minnesota Critical Access Hospital (CAH): A facility designated as a CAH must meet criteria established in Federal legislation as well as criteria required by the state. For CAH criteria, review Minnesota Rural Hospital Flexibility Program and Critical Access Hospital Information on the Minnesota Department of Health (MDH) website.
Allowable Base Year Operating Cost: A hospital’s base year inpatient hospital cost per admission or per day that is adjusted for case mix and excludes property costs.
Base Year: A hospital’s fiscal year from which cost and statistical data are used to establish rates.
Case Mix: A hospital’s distribution of admissions among the diagnostic categories.
Day Outlier: An admission where the length of stay exceeds the geometric mean length of stay for neonate and burn diagnostic categories by one standard deviation and all other diagnostic categories by two standard deviations.
Diagnostic Related Groups (DRGs): An inpatient classification scheme, which provides a means of relating the type of patients a hospital treats to the costs incurred by the hospital to establish prospective payment rates.
Emergency Department Care: Emergency department care must:
- Be provided in a hospital with a designated emergency department; and
- Reflect direct patient care, including active patient assessment, monitoring, and treatment by hospital medical personnel such as physicians, nurses, or lab and X-ray technicians.
Medical records must document the emergency diagnosis and the extent of direct patient care. Emergency department care does not include unattended waiting time.
Emergency department care/emergency services are covered for a medical emergency. This means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in: placing the physical or mental health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, continuation of severe pain, serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or death. Labor and delivery is a medical emergency if it meets this definition.
- The member must be seen by the medical professional on the same day that the member contacted the medical professional in order for the situation to be considered an emergency.
- The situation is not considered an emergency if the member contacts the medical professional and is not given an appointment for the same day of the call.
- Prescheduled services are not considered an emergency.
- Services provided as follow-up to initial emergency care are not considered emergency services.
Inpatient: A patient who has been admitted to a medical institution as an inpatient, as recommended by a physician or dentist, and meets one of the following criteria:
- Receives room, board, and professional services in the institution for a 24-hour period or longer
- Is expected by the institution to receive room, board, and professional services in the institution for a 24-hour period or longer even though it later develops that the patient dies, is discharged, or is transferred to another facility and does not actually stay in the institution for 24 hours
Inpatient Hospital Costs: A hospital’s base year inpatient hospital service costs determined under the cost finding methods of Medicare that includes direct and indirect medical education, without regard to adjustments in payments by Medicare.
Institution for Mental Disease (IMD): A facility with 17 or more beds that is primarily engaged in providing diagnosis, treatments, or care (including medical attention, nursing care, and related services) for people with mental diseases. Adults under age 65 who are patients in an IMD are not eligible for Medical Assistance (Medicaid) unless they are under age 21 at the time of admission.
Local Trade Area Hospital: A hospital with 20 or more Medical Assistance (Medicaid) admissions in the base year that is located in a state other than Minnesota but in a county contiguous to Minnesota and located in a metropolitan statistical area, as determined by Medicare, for the October 1 prior to the most current re-based rate year.
Low-Volume Local Trade Area Hospital: A metropolitan statistical area hospital located outside Minnesota in a county contiguous to Minnesota that has less than 20 Medical Assistance (Medicaid) admissions in the base year.
Operating Costs: Inpatient hospital costs excluding property costs.
Outpatient: A patient of an organized medical facility or distinct part of that facility who is expected by the facility to receive and who does receive professional services for less than a 24-hour period regardless of the hour of admission, whether or not a bed is used, or whether or not the patient remains in the facility past midnight.
Outpatient Hospital Services: Preventive, diagnostic, therapeutic, rehabilitative, or palliative services that are provided to outpatients as follows:
- By or under the direction of a physician or dentist
- By an institution that is licensed or formally approved as a hospital by an officially designated authority for state standard setting and meets the requirements for participation in Medicare as a hospital
Outpatient Observation Status: Observation status is care received in a hospital facility that is not dependent on location, medical department, or whether a patient bed is assigned to the member. PrimeWest Health uses Medicare criteria for billing observation status.
Outpatient observation services are paid for up to 48 hours. Observation services will be considered for unusual circumstances up to 72 hours with documentation.
Patient: An individual who is receiving needed professional services that are directed by a licensed practitioner of the healing arts toward the maintenance, improvement, or protection of health or lessening of illness, disability, or pain.
Property Costs: Inpatient hospital costs, including depreciation, interest, rents and leases, property taxes, and property insurance.
Rate Year: A calendar year from January 1 through December 31.
Trim Point: That number of inpatient days beyond which an admission is a day outlier.
PW_03-19_135
Updated_03/14/2019
