View the Illinois Medicaid Inpatient Acute Reimbursement (APR-DRG Payment)

The reason for rejecting or returning the claim, if applicable.

The facility’s ten-digit National Provider Identification (NPI) number required on all claims.

The effective date of the current contract rates.

The area rate based on statewide standardized amount. The labor portion is adjusted by Medicare IPPS wage index without the 3.5% Smart Act payment reduction.

The fixed-loss amount of the system threshold used to determine the outlier threshold set by the state Medicaid. This threshold amount is used in the cost outlier calculation.

Factor assigned by state for individual hospitals to be used in the psych total expected calculation.

Factor assigned by state for individual hospitals to be used in the rehab total expected calculation.

The Marginal Ratio used in the cost outlier calculation based on the Severity of Illness level.

• If the SOI is 1 or 2 then the marginal ratio is 0.8000.
• If the SOI is 3 or 4 then the marginal ratio is 0.9500.

The SMART Act percentage used in the reimbursement calculation.

• If a facility does not meet the criteria for designation as a Safety Net or Critical Access hospital then it is subject to the reduction in reimbursement.
• This percentage is displayed and used in the total reimbursement calculation.

Note: This field is displayed only when the value is less than 100%.

The reimbursement type, either Expected or RA, if applicable (the latest RA is shown if there are multiple RAs).

The APR-DRG code used to group and price the claim.

The Severity of Illness value.

• Valid SOI values are 1, 2, 3, 4, or blank.
• Each APR-DRG has four weight values based on the SOI.

The adjustor factor defined by the state that is applied to the APR-DRG Base Amount for the following service / facility combinations:

• Transplant discharges, neonate and maternity services at Perinatal Level III hospitals.
• Trauma DRGs at Level 1 and Level 2 Trauma hospitals.

Note: For all other services, the DRG Policy Adjustor is 1.0.

The APR-DRG weight factor for the APR-DRG.

The number of days covered by IL Medicaid.

The amount of charges covered by IL Medicaid.

The standard payment for the claim based on the weight and base rate which includes any applicable adjustments, depending on agency policy, but excludes the impact of transfers and outliers.

The DRG base payment amount.

The Disproportionate Share Hospital capital costs.

The reimbursement for Indirect Medical Education costs.

The Medicaid Percentage Adjustment amount.

The Medicaid High Volume Adjustment amount.

A factor added for "Safety Net" or Critical Access hospitals to calculate the Total Expected Reimbursement.

"Safety Net" or Critical Access hospitals are exempt from the SMART Act reduction.

The cost outlier payments, before policy adjusters, made on acute COS 20 claims where the estimated cost exceeds the outlier threshold.

The portion of the total payment for a claim with a patient discharge disposition that the agency defines as a transfer.

Note: The prorated transfer payment for applicable transfer-out cases are capped at the full DRG payment if the claim length of stay plus one day is greater than the DRG average length of stay.

The reimbursement dollar amount per day of service.

The portion of the total payment for additional compensation at eligible Freestanding Psychiatric Hospitals.

The Charge Cap adjustment applied if the allowed amount is greater than the covered charges.

The amount reduced from the Total Expected Reimbursement for facilities that do not meet the criteria for designation as a Safety Net or Critical Access hospital.