<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.sda2e167a-7b6e-4455-8768-b98539c07e0aP0 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } span.sda2e167a-7b6e-4455-8768-b98539c07e0aC0 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000001 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000002 { color: black; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; text-decoration: line-through; margin: 0; padding: 0; } span.sda2e167a-7b6e-4455-8768-b98539c07e0a000003 { color: black; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sda2e167a-7b6e-4455-8768-b98539c07e0aP0-000004 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.40in; text-align: justify; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } span.sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000005 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:03:06"><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000000">67:16:03:06</span></a><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000001">.   Basis of reimbursement -- Inpatient services -- In-state hospitals.</span><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0"> </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">Reimbursement for services provided for a patient admitted to an in-state prospective payment system hospital is based on the diagnosis-related group (DRG), weight factor, and the hospital's</span><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000002"> </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">base rate. Hospital base rates, DRGs, and associated weight factors may be obtained on the department's fee schedule website</span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">.</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0a000003"> </span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">    The department shall </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">calculate the amount of reimbursement by multiplying the base rate by the weight factor of the DRG assigned to the claim</span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">.</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0a000003"> </span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0-000004"><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">In addition to the regular DRG reimbursement, the department shall pay for a cost outlier if the department determines the claim qualifies for the cost outlier. The amount of the cost outlier payment is calculated by subtracting the DRG base payment plus the fixed loss ratio from the allowable estimated cost, multiplied by the marginal cost percentage published on the department's fee schedule website. The estimated cost of a claim is calculated by multiplying the hospital's assigned cost-to-charge ratio by the charges submitted on the claim.</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0a000003"> </span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">    When calculating the rate of reimbursement, the department uses only the diagnosis codes that reflect the services furnished to or on behalf of the eligible </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">patient</span><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0"> and the conditions that affected the treatment or extended the length of the </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">patient</span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">'s stay.</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0a000003"> </span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">    If a patient is transferred, referred, or discharged to another hospital or another type of special care facility and the transfer, referral, or discharge is medically necessary</span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">,</span><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0"> or if a patient leaves the hospital against medical advice, reimbursement is on a </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">prorated basis not to exceed one hundred percent of the allowed DRG payment</span><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">. </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">The prorated payment is calculated by dividing the DRG base payment by the All Patient Refined-Diagnosis Related Group's national average length of stay and multiplying the result by the covered number of days, plus one</span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">.</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0a000003"> </span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">    </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000001">Source:</span><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0"> SL 1975, ch 16, § 1; 1 SDR 30, effective October 13, 1974; 7 SDR 66, 7 SDR 89, effective July 1, 1981; 11 SDR 26, effective August 21, 1984; transferred from § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:03:12"><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000005">67:16:03:12</span></a><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">, 12 SDR 6, effective July 28, 1985; exemptions for certain hospitals transferred to § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:03:06.02"><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000005">67:16:03:06.02</span></a><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">, 13 SDR 8, effective August 3, 1986; 15 SDR 2, effective July 17, 1988; 17 SDR 180, effective May 27, 1991; 22 SDR 143, effective May 9, 1996; 24 SDR 19, effective August 21, 1997; 24 SDR 144, effective April 30, 1998; 25 SDR 116, effective March 24, 1999; 30 SDR 26, effective September 3, 2003; 31 SDR 39, effective September 29, 2004; 36 SDR 215. effective July 1, 2010; 36 SDR 215, adopted June 11, 2010, effective July 1, 2011; 37 SDR 236, effective June 28, 2011; 37 SDR 236, adopted June 8, 2011, effective July 1, 2012; 39 SDR 15, effective August 6, 2012; 40 SDR 15, effective July 31, 2013; 42 SDR 51, effective October 13, 2015</span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">; 52 SDR 126, effective July 1, 2026</span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">.</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">    </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000001">General Authority:</span><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000005">28-6-1</span></a><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">.</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">    </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000001">Law Implemented:</span><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1"><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000005">28-6-1</span></a><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">, </span><a href="https://sdlegislature.gov/Statutes?Statute=28-6-1.1"><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000005">28-6-1.1</span></a><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">.</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0a000003"> </span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">    </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000001">Cross-References:</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">    Basis of reimbursement -- Outpatient services, § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:03:06.01"><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000005">67:16:03:06.01</span></a><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">.</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000001">    </span><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">Basis of </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">reimbursement</span><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0"> -- Inpatient services -- </span><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">In-state critical access hospitals</span><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">, § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:03:06.03"><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000005">67:16:03:06.03</span></a><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">.</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">    Definitions, "Website" (Fee Schedule Website), subdivision </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:01:01"><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000005">67:16:01:01</span></a><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">(18).</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">    Reimbursement of outpatient laboratory services, § </span><a href="https://sdlegislature.gov/Rules?Rule=67:16:03:06.07"><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0-000005">67:16:03:06.07</span></a><span class="sda2e167a-7b6e-4455-8768-b98539c07e0aC0">.</span></p><p dir="ltr" class="sda2e167a-7b6e-4455-8768-b98539c07e0aP0"><span xml:space="preserve" class="sda2e167a-7b6e-4455-8768-b98539c07e0a000003"> </span></p></div></body></html>