| (C) Interim claim reimbursement for a rural hospital
is determined by multiplying the amount of a hospital's outpatient
allowable charges after applying any reductions to allowable charges
made under paragraph (1) of this subsection by the outpatient interim
rate in effect on the date of service as described in subparagraph
(A) of this paragraph.
(D) Interim claim reimbursement determined in subparagraph
(C) of this paragraph will not be cost-settled for services rendered
on or after September 1, 2021.
(c) Outpatient hospital surgery. Outpatient hospital
non-emergency surgery is reimbursed in accordance with the methodology
for ambulatory surgical centers as described in §355.8121 of
this subchapter (relating to Reimbursement).
(d) Outpatient hospital imaging.
(1) For services provided on and after the date that
the modernized MMIS becomes operational, all hospitals will be reimbursed
based on an outpatient prospective payment system (OPPS). The OPPS
used for reimbursement is the 3M™ Enhanced Ambulatory Patient
Groups (EAPG) calculator.
(2) For services prior to the date that the modernized
MMIS becomes operational, for all hospitals except rural hospitals,
as defined in §355.8052 of this division, outpatient hospital
imaging services are not reimbursed under the outpatient reimbursement
methodology described in subsection (b) of this section. Outpatient
hospital imaging services are reimbursed according to an outpatient
hospital imaging service fee schedule that is based on a percentage
of the Medicare Outpatient Prospective Payment System fee schedule
for similar services. If a resulting fee for a service provided to
any Medicaid beneficiary is greater than 125 percent of the Medicaid
adult acute care fee for a similar service, the fee is reduced to
125 percent of the Medicaid adult acute care fee.
(3) For services prior to the date that the modernized
MMIS becomes operational, for rural hospitals, outpatient hospital
imaging services are reimbursed based on a percentage of the Medicare
Outpatient Prospective Payment System fee schedule for similar services.
(e) Minimum Fee Schedule. Effective September 1, 2020,
Managed Care Organizations are required to reimburse rural hospitals
based on a minimum fee schedule. The minimum fee schedules are the
rates specific to rural hospitals, as described in subsections (b)
- (d) of this section.
|
| Source Note: The provisions of this §355.8061 adopted to be effective May 30, 1977, 2 TexReg 1929; amended to be effective February 29, 1984, 9 TexReg 1041; amended to be effective April 19, 1985, 10 TexReg 1148; amended to be effective July 1, 1986, 11 TexReg 2754; transferred effective September 1, 1993, as published in the Texas Register September 7, 1993, 18 TexReg 5978; amended to be effective February 28, 1994, 19 TexReg 1041; amended to be effective December 7, 1995, 20 TexReg 9851; amended to be effective January 5, 1998, 22 TexReg 12763; transferred effective September 1, 1997, as published in theTexasRegister December 11, 1998, 23 TexReg 12660; amended to be effective October 21, 1999, 24 TexReg 8957; amended to be effective January 3, 2002, 26 TexReg 10847; amended to be effective December 4, 2002, 27 TexReg 11074; amended to be effective August 12, 2004, 29 TexReg 7667; amended to be effective April 1, 2007, 32 TexReg 1720; amended to be effective September 1, 2007, 32 TexReg 5343; amended to be effective August 3, 2008, 33 TexReg 5913; amended to be effective August 26, 2008, 33 TexReg 6779; amended to be effective September 1, 2009, 34 TexReg 5661; amended to be effective September 1, 2010, 35 TexReg 6512; amended to be effective September 1, 2011, 36 TexReg 5344; amended to be effective September 1, 2013, 38 TexReg 5448; amended to be effective September 1, 2015, 40 TexReg 5318; amended to be effective January 31, 2017, 42 TexReg 307; amended to be effective October 24,2021,46 TexReg 7206; amended to be effective November 26, 2023, 48 TexReg 6735 |
