(1) "Acute care psychiatric hospital" means a psychiatric facility accredited by the Joint Commission on Accreditation of Health Care Organizations that is devoted to the provision of inpatient psychiatric care for persons under the age of 21 and licensed as a hospital by:

(a) the department; or

(b) an equivalent agency in the state in which the facility is located.

(2) "Administratively necessary days" or "inappropriate level of care services" means those services for which alternative placement of a patient is planned and/or effected and for which there is no medical necessity for acute level inpatient hospital care.

(3) "All patient refined diagnosis related groups (APR-DRGs)" means DRGs that classify each inpatient case based on claim information such as diagnosis, procedures performed, patient age, patient sex, and discharge status.

(4) "Bad debt" means inpatient and outpatient hospital services provided in which full payment is not received from the patient or from a third party payor, for which the provider expected payment and the persons are unable or unwilling to pay their bill. Bad debts may be for services provided to patients who have no health insurance or patients who are underinsured and are net of payments made toward these services. For the purpose of uncompensated care, bad debt is measured on the basis of revenue forgone, at full established rates, and bad debt does not include either provider discounts or Medicare bad debt.

(5) "Base price" means a dollar amount, including capital expenses, that is reviewed by the department each year to allow for appropriation neutrality.

(6) "Border hospital" means a hospital located outside Montana, but no more than 100 miles from the border.

(7) "Center of Excellence" means a hospital specifically designated by the department as being able to provide a higher level of comprehensive care that is not available elsewhere.

(8) "Charity care" means inpatient and outpatient hospital services in which hospital policies determine the patient is unable to pay and did not expect to receive full reimbursement. Charity care results from a provider's policy to provide health care services free of charge (or where only partial payment is expected) to individuals who meet certain financial criteria. For the purpose of uncompensated care, charity care is measured on the basis of revenue forgone, at full established rates. Charity care does not include contractual write-offs.

(9) "Cost based hospital" means a licensed acute care hospital that is reimbursed on the basis of allowable cost.

(10) "Cost outlier" means an additional payment for unusually high cost case that exceeds the cost outlier thresholds as set forth in ARM 37.86.2916.

(11) "Critical access hospital" means a limited-service rural hospital licensed by the Montana Department of Public Health and Human Services.

(12) "Direct nursing care" means the care given directly to the patient which requires the skills and expertise of an RN or LPN.

(13) "Discharging hospital" means a hospital, other than a transferring hospital, that formally discharges an inpatient. Release of a patient to another hospital, as described in (31) or a leave of absence from the hospital will not be recognized as a discharge. A patient who dies in the hospital is considered a discharge.

(14) "Distinct part psychiatric unit" means a psychiatric unit of an acute care general hospital that meets the requirements of 42 CFR part 412 (2008).

(15) "Distinct part rehabilitation unit" means a rehabilitation unit of an acute care general hospital that meets the requirements in 42 CFR 412.25 and 412.29 (1992).

(16) "Exempt hospital" means, for purposes of determining whether a hospital is exempt from the prospective payment system under ARM 37.86.2905, an acute care hospital that is located in a Montana county designated on or before July 1, 1991 as continuum code 8 or continuum code 9 by the United States Department of Agriculture under its rural-urban continuum codes for metro and nonmetro counties.

(17) "Hospital reimbursement adjustor (HRA)" means a payment to a Montana hospital as specified in ARM 37.86.2928 and 37.86.2940.

(18) "Hospital resident" means a recipient who is unable to be cared for in a setting other than the acute care hospital as provided in ARM 37.86.2921.

(19) "Inpatient" means a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. A person generally is considered an inpatient if formally admitted as an inpatient with an expectation that the patient will remain more than 24 hours. The physician or other practitioner is responsible for deciding whether the patient should be admitted as an inpatient. Inpatient hospital admissions are subject to retrospective review by the Medicaid peer review organization (PRO) to determine whether the inpatient admission was medically necessary for Medicaid payment purposes.

(20) "Inpatient hospital services" means services that are ordinarily furnished in an acute care hospital for the care and treatment of an inpatient under the direction of a physician, dentist, or other practitioner as permitted by federal law, and that are furnished in an institution that:

(a) is maintained primarily for the care and treatment of patients with disorders other than:

(i) tuberculosis; or

(ii) mental diseases, except as provided in (19)(d);

(b) is licensed or formally approved as an acute care hospital by the officially designated authority in the state where the institution is located;

(c) except as otherwise permitted by federal law, meets the requirements for participation in Medicare as a hospital and has in effect a utilization review plan that meets the requirements of 42 CFR 482.30; or

(d) provides inpatient psychiatric hospital services for individuals under age 21 pursuant to ARM Title 37, chapter 88, subchapter 11.

(21) "Long term care hospital (LTCH)" means an acute care hospital as defined in 42 CFR 412.

(22) "Low income utilization rate" means a hospital's percentage rate as specified in ARM 37.86.2935.

(23) "Medicaid inpatient utilization rate" means a hospital's percentage rate as specified in ARM 37.86.2932.

(24) "Preferred out-of-state hospital" means a hospital located more than 100 miles outside the borders of Montana that has signed a contract with the department to provide specialized services prior approved by the department. The classification of preferred out-of-state hospital is eliminated effective September 30, 2008.

(25) "Prospective payment system (PPS) hospital" means a hospital reimbursed pursuant to the diagnosis related group (DRG) system. DRG hospitals are classified as such by the Centers for Medicare and Medicaid Services (CMS) in accordance with 42 CFR part 412 (2008).

(26) "Qualified rate adjustment payment" (QRA) means an additional payment as provided in ARM 37.86.2910 to a county owned, county operated, or partially county funded rural hospital in Montana where the hospital's most recently reported costs are greater than the reimbursement received from Montana Medicaid for inpatient care.

(27) "Relative weight" means a weight assigned from a national database from 3M that reflects the typical resources consumed per APR-DRG.

(28) "Routine disproportionate share hospital" means a hospital in Montana which meets the criteria of ARM 37.86.2931.

(29) "Rural hospital" means for purposes of determining disproportionate share hospital payments, an acute care hospital that is located within a "rural area" as defined in 42 CFR 412.62(f)(iii).

(30) "Sole community hospital" means a DRG reimbursed hospital classified as such by the Centers for Medicare and Medicaid Services (CMS) in accordance with 42 CFR 412.92(a) through (d) and/or hospitals with less than 51 beds.

(31) "Supplemental disproportionate share hospital" means a hospital in Montana which meets the criteria in ARM 37.86.2925 and 37.86.2931.

(32) "Transferring hospital" means a hospital that formally releases an inpatient to another inpatient hospital or inpatient unit of a hospital.

(33) "Uncompensated care" means hospital services provided in which no payment is received from the patient or from a third party payor. Uncompensated care includes charity care and bad debts.

(34) "Urban hospital" means an acute care hospital that is located within a metropolitan statistical area, as defined in 42 CFR 412.62(f)(2).