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Medicaid Patient Volume and Average Length of Stay Eligibility

Medicaid Patient Volume: Eligible Hospitals (EHs) must meet a 10 percent Medicaid patient volume threshold.

  • Patient Volume reporting period: any continuous 90-day period during the prior fiscal year preceding the payment year.
  • Total encounters (denominator): all encounters that the EH provided during the Patient Volume reporting period.
  • Medicaid encounters (numerator): all services (in the denominator) provided in a day by a specific provider to a Medicaid-enrolled individual during the Patient Volume reporting period. This includes:
    • Services in which Medicaid (including the program formerly known as "Healthy Kids Gold" and out-of-state Medicaid and Medicaid-managed care programs) paid for part or all of the services (including premiums, co-payments, and/or cost sharing); or
    • Encounters where Medicaid paid zero dollars ($0) where Medicare (in the case of patients that are dually eligible for both Medicaid and Medicare) or another third party paid for the encounter; or
    • Encounters provided to Medicaid beneficiaries for which no payments were received; or
    • Medical services provided to Medicaid beneficiaries that were not covered under New Hampshire's Medicaid program.

Examples of encounters that CAN be included are:

  • Claims denied due to service limitation audits;
  • Claims denied due to non-covered services;
  • Claims denied due to timely filing; and
  • Services rendered on Medicaid members that were not billed due to the provider's understanding of Medicaid business rules.

Examples of encounters that CANNOT be included are:

  • Claims denied due to the provider being ineligible for the date of service; and
  • Claims denied due to the member being ineligible for the date of service.

Average Length of Stay: the average length of stay must be 25 days or less (based on the total Inpatient Bed Days and total Discharges from the 12-month period of the most recently filed Medicare Cost Report).


 
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New Hampshire Department of Health and Human Services
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