1. (1) Medicaid does not pay for Provider Preventable Conditions (PPC).

   1. (a) Medicaid utilizes the Medicaid Severity-Diagnosis Related Group (MS-DRG) to identify a PPC.
   2. (b) For inpatient hospital claims, Medicaid does not cover PPCs in Medicare crossover patients.

   3. (c) To qualify as a PPC, one of the Medicare-listed diagnoses must develop during hospitalization.

      1. (i) When present on admission, these diagnoses are not considered to be a PPC for that hospitalization.
      2. (ii) Providers are expected to identify Present on Admission (POA) status for all diagnoses on each claim according to correct coding standards.

   4. (d) Providers must assure that all PPC-related diagnoses, services, and charges are noted as "non-covered charges" on the claim.

      1. (i) The Department does not use non-covered charges in calculating the hospital reimbursement.

   5. (e) The Department shall deny PPC-related claims that result in an outlier payment and medical records will be required.

      1. (i) Providers will receive Remittance Advice (RA) that confirms the occurrence of a PPC outlier claim.
      2. (ii) The Department requires providers to know which medical records and other required documents are needed.

      3. (iii) Upon RA notification of a PPC, the provider shall submit the following documents within 30 days:

         1. (A) "Outlier PPC Medical Record Documentation Submission Form";
         2. (B) Complete medical records from the associated hospital stay;
         3. (C) Itemized bill (tab de-limited text file or Excel spreadsheet), including a detailed listing of PPC-related charges as non-covered charges, with total charges matching the total charges submitted on the claim.
   6. (f) The Department will review and, if appropriate, re-process the claim based upon the review of the required documents submitted within the 30-day period of RA notification.
   7. (g) The Department shall deny review of the claim unless the required documentation is submitted within 30 days of RA notification.
   8. (h) The Department requires providers to report PPCs in accordance with Section R414-1-28.

KEY: Medicaid

Date of Last Change: November 10, 2023

Notice of Continuation: September 14, 2022

Authorizing, and Implemented or Interpreted Law: 26B-1-213; 26B-3-108; 26B-3-110