<html> <head> <title>Rule 67:16:03:01 Definitions.</title> <META NAME="Keywords" Content="Administrative Rules 67:16:03:01"> <META NAME="Description" Content="Administrative Rules 67:16:03:01 Definitions."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin:0in; margin-bottom:.0001pt; text-align:justify; font-size:12.0pt; font-family:"Times New Roman","serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal><a name="_GoBack"></a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>67:16:03:01.&nbsp;&nbsp;Definitions.</b> Terms used in this chapter mean:</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;&quot;Benefit period,&quot; a period of days for which an individual may receive benefits for inpatient hospital services;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;&quot;Case mix index,&quot; the sum of the DRG weight factors for all Medicaid discharges for a hospital during a specific time span divided by the number of discharges;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;&quot;Cost outlier,&quot; a hospital claim with 70 percent of the billed charges exceeding the greater of 1.5 times the standard DRG payment amount or the outlier threshold available on the department's fee schedule website;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (4)&nbsp;&nbsp;&quot;Diagnosis-related group,&quot; &quot;DRG,&quot; a classification assigned to an inpatient hospital service claim based on the patient's age and sex, the principal and secondary diagnoses, the procedures performed, and the discharge status;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (5)&nbsp;&nbsp;&quot;Emergency hospital care,&quot; the care necessary to prevent the death or serious impairment of the health of the recipient after the sudden onset of a medical condition that is manifested by symptoms of sufficient severity so as to be life-threatening or require immediate medical intervention;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (6)&nbsp;&nbsp;&quot;Hospital services,&quot; items and services provided on the hospital's premises to a patient by a hospital under the direction of a physician or a dentist;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (7)&nbsp;&nbsp;&quot;Inpatient,&quot; a patient who has been admitted to a hospital on the recommendation of a physician or a dentist;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (8)&nbsp;&nbsp;&quot;Outpatient,&quot; a patient who receives professional services at a participating hospital, but is not provided with room, board, and services on a 24-hour basis;</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (9)&nbsp;&nbsp;&quot;Participating hospital,&quot; a hospital owned by the state in which it is located or licensed by the state licensing agency of the state in which it is located, certified by Medicare under Title XVIII of the Social Security Act, as amended to January 1, 2010, which agrees to participate under the medical assistance program; and</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (10)&nbsp;&nbsp;&quot;Target amount,&quot; a hospital's average Medicaid cost per discharge for routine services divided by its case mix index.</p> <p class=MsoNormal>&nbsp;</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> SL 1975, ch 16, &#167;&nbsp;1; 1 SDR 30, effective October 13, 1974; 4 SDR 35, effective December 22, 1977; 7 SDR 23, effective September 18, 1980; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 12 SDR 6, effective July 28, 1985; 15 SDR 2, effective July 17, 1988; 17 SDR 180, effective May 27, 1991; 17 SDR 200, effective July 1, 1991; 19 SDR 128, effective March 10, 1993; 20 SDR 135, effective February 22, 1994; 20 SDR 144, effective March 10, 1994; 21 SDR 172, effective April 3, 1995; 22 SDR 143, May 9, 1996; 23 SDR 192, effective May 22, 1997; 24 SDR 144, effective April 30, 1998; 25 SDR 116, effective March 24, 1999; 26 SDR 157, effective June 7, 2000; 28 SDR 1, effective July 18, 2001; 28 SDR 115, effective February 27, 2002; 30 SDR 26, effective September 3, 2003; 31 SDR 107, effective February 1, 2005; 34 SDR 68, effective September 12, 2007; 37 SDR 53, effective September 23, 2010; 42 SDR 51, effective October 13, 2015.</p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1(1)(2)(3).</A></p> <p class=MsoNormal>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1">28-6-1(1)(2)(3)</A>, <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=28-6-1.1">28-6-1.1.</A></p> <p class=MsoNormal>&nbsp;</p> </div> </body> </html>