Rule 511-5-10-.07. Reimbursement of Cost

Based on the guidelines outlined below, reimbursement shall be made for standard diagnostic evaluation, cancer treatment, and facility costs incurred to provide oncology care to enrolled patients.

1. 1) Upon patient enrollment, participating facilities may submit claims for services provided within 90 days prior to the Program's receipt of the patient application.
2. 2) The Program may consider payment of additional outstanding oncology service claims based upon available funds.
3. 3) Payment for medications is based upon current program policies, available funds and facility agreements.
4. 4) No reimbursement will be made to any facility for any services provided prior to the Department's signature date on the Cancer State Aid participation agreement.

5. 5) Cancer State Aid patients shall not be billed for eligible cancer related services provided to the patient during their enrollment period for the fiscal year, up to the established Program maximums or the amount assigned for the patient's care by the Program.

   1. a) It is the responsibility of the facility to submit all claims for payment within 60 days of the date of treatment.
   2. b) Claims received after the 60 day requirement are not eligible for Cancer Sate Aid payment and may not be billed to the patient.
   3. c) At the discretion of the Cancer State Aid Program denied claims may be paid provided funds are available and the Program does not have a waiting list for program enrollment.

6. 6) Hospitals

   Participating hospitals must provide the most recent independent certified audit. The audit documents the facility's total expenses and total patient charges. The ratio of these expenses and charges is used to establish the percent of billed charges that will be reimbursed for the current state fiscal year by the Cancer State Aid Program. This number is referred to as the reimbursement percentage.

   Hospitals are reimbursed at 100% of the calculated reimbursement percentage up to the allowed Cancer State Aid maximums per enrollment year.

   The Cancer State Aid Program shall determine limitations on payment for services based on available funding for the fiscal year in which the patient is approved.

   Whenever possible, care should be provided in the most cost effective setting.

   Hospice care is not eligible for Cancer State Aid reimbursement.

7. 7) Free-Standing Radiation Therapy Centers

   1. a) Reimbursement of cost shall be made up to the current fiscal year maximum determined by the Program for this provider category, and for procedures as defined in the participation agreement.

8. 8) Physician Group Practices or Medical Treatment Centers

   1. a) Reimbursement shall be made for diagnostic services for suspected cancers, cancer treatment services, and evaluation and management services related to cancer care provided on an outpatient basis only.
   2. b) Reimbursement of cost shall be made up to the current fiscal year maximums determined by the Program for this provider category, and for procedures as defined in the participation agreement.

9. 9) Other or Special Vendors

   Pharmacies, home health and medical suppliers must have a current signed and approved Cancer State Aid statement of participation/agreement.

Authority: O.C.G.A. Secs. 31-2A-6, 31-15-5.

History. Previously rule 290-5-10-.07. Original Rule entitled "Reimbursement of Cost" adopted. F. Apr. 11, 2012; eff. May 1, 2012.