Font Size

SPA 19-0013 OPPS Reimbursement submitted to CMS

State Plan Amendment (SPA) 19-0013 Outpatient Prospective Payment System (OPPS) Reimbursement is being submitted to update hospital outpatient reimbursement as follows, effective July 1, 2019:

1. Remove specific diagnosis codes related to Never Events and refer to the diagnosis code descriptions,
2. Use the Medicare outpatient Addendum B as of January 1 of each year as published by CMS to calculate the Medicaid OPPS fee,
3. Apply the multiple discounting policy to dental procedures billed on the hospital outpatient claim to price the highest allowed dental procedure at one hundred percent (100%) of the allowed amount or published fee and price all subsequent dental procedures at twenty-five percent (25%) of the allowed amount or published fee, and
4. Require prior authorization on all dental procedures performed in the outpatient hospital setting.

For more information read the submitted draft pages.