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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