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Electronic Code of Federal Regulations

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e-CFR Data is current as of November 20, 2014

Title 42Chapter IVSubchapter BPart 412


TITLE 42—Public Health

CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES

SUBCHAPTER B—MEDICARE PROGRAM

PART 412—PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES

rule

Subpart A—GENERAL PROVISIONS

§412.1
Scope of part.
§412.2
Basis of payment.
§412.3
Admissions.
§412.4
Discharges and transfers.
§412.6
Cost reporting periods subject to the prospective payment systems.
§412.8
Publication of schedules for determining prospective payment rates.
§412.10
Changes in the DRG classification system.
rule

Subpart B—HOSPITAL SERVICES SUBJECT TO AND EXCLUDED FROM THE PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT OPERATING COSTS AND INPATIENT CAPITAL-RELATED COSTS

§412.20
Hospital services subject to the prospective payment systems.
§412.22
Excluded hospitals and hospital units: General rules.
§412.23
Excluded hospitals: Classifications.
§412.25
Excluded hospital units: Common requirements.
§412.27
Excluded psychiatric units: Additional requirements.
§412.29
Classification criteria for payment under the inpatient rehabilitation facility prospective payment system.
§412.30
[Reserved]
rule

Subpart C—CONDITIONS FOR PAYMENT UNDER THE PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT OPERATING COSTS AND INPATIENT CAPITAL-RELATED COSTS

§412.40
General requirements.
§412.42
Limitations on charges to beneficiaries.
§412.44
Medical review requirements: Admissions and quality review.
§412.46
Medical review requirements.
§412.48
Denial of payment as a result of admissions and quality review.
§412.50
Furnishing of inpatient hospital services directly or under arrangements.
§412.52
Reporting and recordkeeping requirements.
rule

Subpart D—BASIC METHODOLOGY FOR DETERMINING PROSPECTIVE PAYMENT FEDERAL RATES FOR INPATIENT OPERATING COSTS

§412.60
DRG classification and weighting factors.
§412.62
Federal rates for inpatient operating costs for fiscal year 1984.
§412.63
Federal rates for inpatient operating costs for Federal fiscal years 1984 through 2004.
§412.64
Federal rates for inpatient operating costs for Federal fiscal year 2005 and subsequent fiscal years.
rule

Subpart E—DETERMINATION OF TRANSITION PERIOD PAYMENT RATES FOR THE PROSPECTIVE PAYMENT SYSTEM FOR INPATIENT OPERATING COSTS

§412.70
General description.
§412.71
Determination of base-year inpatient operating costs.
§412.72
Modification of base-year costs.
§412.73
Determination of the hospital-specific rate based on a Federal fiscal year 1982 base period.
§412.75
Determination of the hospital-specific rate for inpatient operating costs based on a Federal fiscal year 1987 base period.
§412.76
Recovery of excess transition period payment amounts resulting from unlawful claims.
§412.77
Determination of the hospital-specific rate for inpatient operating costs for sole community hospitals based on a Federal fiscal year 1996 base period.
§412.78
Determination of the hospital-specific rate for inpatient operating costs for sole community hospitals based on a Federal fiscal year 2006 base period.
§412.79
Determination of the hospital-specific rate for inpatient operating costs for Medicare-dependent, small rural hospitals based on a Federal fiscal year 2002 base period.
rule

Subpart F—PAYMENTS FOR OUTLIER CASES, SPECIAL TREATMENT PAYMENT FOR NEW TECHNOLOGY, AND PAYMENT ADJUSTMENT FOR CERTAIN REPLACED DEVICES

Payment for Outlier Cases

§412.80
Outlier cases: General provisions.
§412.82
Payment for extended length-of-stay cases (day outliers).
§412.84
Payment for extraordinarily high-cost cases (cost outliers).
§412.86
Payment for extraordinarily high-cost day outliers.

Additional Special Payment for Certain New Technology

§412.87
Additional payment for new medical services and technologies: General provisions.
§412.88
Additional payment for new medical service or technology.

Payment Adjustment for Certain Replaced Devices

§412.89
Payment adjustment for certain replaced devices.
rule

Subpart G—SPECIAL TREATMENT OF CERTAIN FACILITIES UNDER THE PROSPECTIVE PAYMENT SYSTEM FOR INPATIENT OPERATING COSTS

§412.90
General rules.
§412.92
Special treatment: Sole community hospitals.
§412.96
Special treatment: Referral centers.
§412.98
[Reserved]
§412.100
Special treatment: Renal transplantation centers.
§412.101
Special treatment: Inpatient hospital payment adjustment for low-volume hospitals.
§412.102
Special treatment: Hospitals located in areas that are changing from urban to rural as a result of a geographic redesignation.
§412.103
Special treatment: Hospitals located in urban areas and that apply for reclassification as rural.
§412.104
Special treatment: Hospitals with high percentage of ESRD discharges.
§412.105
Special treatment: Hospitals that incur indirect costs for graduate medical education programs.
§412.106
Special treatment: Hospitals that serve a disproportionate share of low-income patients.
§412.107
Special treatment: Hospitals that receive an additional update for FYs 1998 and 1999.
§412.108
Special treatment: Medicare-dependent, small rural hospitals.
§412.109
Special treatment: Essential access community hospitals (EACHs).
rule

Subpart H—PAYMENTS TO HOSPITALS UNDER THE PROSPECTIVE PAYMENT SYSTEMS

§412.110
Total Medicare payment.
§412.112
Payments determined on a per case basis.
§412.113
Other payments.
§412.115
Additional payments.
§412.116
Method of payment.
§412.120
Reductions to total payments.
§412.125
Effect of change of ownership on payments under the prospective payment systems.
§412.130
Retroactive adjustments for incorrectly excluded hospitals and units.
§412.140
Participation, data submission, and validation requirements under the Hospital Inpatient Quality Reporting (IQR) Program.
rule

Subpart I—ADJUSTMENTS TO THE BASE OPERATING DRG PAYMENT AMOUNTS UNDER THE PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT OPERATING COSTS

§412.150
Basis and scope of subpart.

Payment Adjustments Under the Hospital Readmissions Reduction Program

§412.152
Definitions for the Hospital Readmissions Reduction Program.
§412.154
Payment adjustments under the Hospital Readmissions Reduction Program.
§§412.155-412.159
[Reserved]

Incentive Payments Under the Hospital Value-Based Purchasing Program

§412.160
Definitions for the Hospital Value-Based Purchasing (VBP) Program.
§412.161
Applicability of the Hospital Value-Based Purchasing (VBP) Program
§412.162
Process for reducing the base operating DRG payment amount and applying the value-based incentive payment amount adjustment under the Hospital Value-Based Purchasing (VBP) Program.
§412.163
Process for making hospital-specific performance information under the Hospital Value-Based Purchasing (VBP) Program available to the public.
§412.164
Measure selection under the Hospital Value-Based Purchasing (VBP) Program.
§412.165
Performance scoring under the Hospital Value-Based Purchasing (VBP) Program.
§412.167
Appeal under the Hospital Value-Based Purchasing (VBP) Program.
§§412.168-412.169
[Reserved]

Payment Adjustments Under the Hospital-Acquired Condition Reduction Program

§§412.170
Definitions for the Hospital-Acquired Condition Reduction Program.
§412.172
Payment adjustments under the Hospital-Acquired Condition Reduction Program.
rule

Subpart J—[RESERVED]

rule

Subpart K—PROSPECTIVE PAYMENT SYSTEM FOR INPATIENT OPERATING COSTS FOR HOSPITALS LOCATED IN PUERTO RICO

§412.200
General provisions.
§412.204
Payment to hospitals located in Puerto Rico.
§412.208
Puerto Rico rates for Federal fiscal year 1988.
§412.210
Puerto Rico rates for Federal fiscal years 1989 through 2003.
§412.211
Puerto Rico rates for Federal fiscal year 2004 and subsequent fiscal years.
§412.212
National rate.
§412.220
Special treatment of certain hospitals located in Puerto Rico.
rule

Subpart L—THE MEDICARE GEOGRAPHIC CLASSIFICATION REVIEW BOARD

Criteria and Conditions for Redesignation

§412.230
Criteria for an individual hospital seeking redesignation to another rural area or an urban area.
§412.232
Criteria for all hospitals in a rural county seeking urban redesignation.
§412.234
Criteria for all hospitals in an urban county seeking redesignation to another urban area.
§412.235
Criteria for all hospitals in a State seeking a statewide wage index redesignation.

Composition and Procedures

§412.246
MGCRB members.
§412.248
Number of members needed for a decision or a hearing.
§412.250
Sources of MGCRB's authority.
§412.252
Applications.
§412.254
Proceedings before MGCRB.
§412.256
Application requirements.
§412.258
Parties to MGCRB proceeding.
§412.260
Time and place of the oral hearing.
§412.262
Disqualification of an MGCRB member.
§412.264
Evidence and comments in MGCRB proceeding.
§412.266
Availability of wage data.
§412.268
Subpoenas.
§412.270
Witnesses.
§412.272
Record of proceedings before the MGCRB.
§412.273
Withdrawing an application, terminating an approved 3-year reclassification, or canceling a previous withdrawal or termination.
§412.274
Scope and effect of an MGCRB decision.
§412.276
Timing of MGCRB decision and its appeal.
§412.278
Administrator's review.
§412.280
Representation.
rule

Subpart M—PROSPECTIVE PAYMENT SYSTEM FOR INPATIENT HOSPITAL CAPITAL COSTS

General Provisions

§412.300
Scope of subpart and definition.
§412.302
Introduction to capital costs.
§412.304
Implementation of the capital prospective payment system.

Basic Methodology for Determining the Federal Rate for Capital-Related Costs

§412.308
Determining and updating the Federal rate.
§412.312
Payment based on the Federal rate.
§412.316
Geographic adjustment factors.
§412.320
Disproportionate share adjustment factor.
§412.322
Indirect medical education adjustment factor.

Determination of Transition Period Payment Rates for Capital-Related Costs

§412.324
General description.
§412.328
Determining and updating the hospital-specific rate.
§412.331
Determining hospital-specific rates in cases of hospital merger, consolidation, or dissolution.
§412.332
Payment based on the hospital-specific rate.
§412.336
Transition period payment methodologies.
§412.340
Fully prospective payment methodology.
§412.344
Hold-harmless payment methodology.
§412.348
Exception payments.
§412.352
Budget neutrality adjustment.

Special Rules for Puerto Rico Hospitals

§412.370
General provisions for hospitals located in Puerto Rico.
§412.374
Payments to hospitals located in Puerto Rico.
rule

Subpart N—PROSPECTIVE PAYMENT SYSTEM FOR INPATIENT HOSPITAL SERVICES OF INPATIENT PSYCHIATRIC FACILITIES

§412.400
Basis and scope of subpart.
§412.402
Definitions.
§412.404
Conditions for payment under the prospective payment system for inpatient hospital services of psychiatric facilities.
§412.405
Preadmission services as inpatient operating costs under the inpatient psychiatric facility prospective payment system.
§412.422
Basis of payment.
§412.424
Methodology for calculating the Federal per diem payment amount.
§412.426
Transition period.
§412.428
Publication of Updates to the inpatient psychiatric facility prospective payment system.
§412.432
Method of payment under the inpatient psychiatric facility prospective payment system.
§412.434
Reconsideration and appeals procedures of Inpatient Psychiatric Facilities Quality Reporting (IPFQR) Program decisions.
rule

Subpart O—PROSPECTIVE PAYMENT SYSTEM FOR LONG-TERM CARE HOSPITALS

§412.500
Basis and scope of subpart.
§412.503
Definitions.
§412.505
Conditions for payment under the prospective payment system for long-term care hospitals.
§412.507
Limitation on charges to beneficiaries.
§412.508
Medical review requirements.
§412.509
Furnishing of inpatient hospital services directly or under arrangement.
§412.511
Reporting and recordkeeping requirements.
§412.513
Patient classification system.
§412.515
LTC-DRG weighting factors.
§412.517
Revision of LTC-DRG group classifications and weighting factors.
§412.521
Basis of payment.
§412.523
Methodology for calculating the Federal prospective payment rates.
§412.525
Adjustments to the Federal prospective payment.
§412.526
Payment provisions for a “subclause (II)” long-term care hospital.
§412.529
Special payment provision for short-stay outliers.
§412.531
Special payment provisions when an interruption of a stay occurs in a long-term care hospital.
§412.533
Transition payments.
§412.534
Special payment provisions for long-term care hospitals within hospitals and satellites of long-term care hospitals.
§412.535
Publication of the Federal prospective payment rates.
§412.536
Special payment provisions for long-term care hospitals and satellites of long-term care hospitals that discharged Medicare patients admitted from a hospital not located in the same building or on the same campus as the long-term care hospital or satellite of the long-term care hospital.
§412.540
Method of payment for preadmission services under the long-term care hospital prospective payment system.
§412.541
Method of payment under the long-term care hospital prospective payment system.
rule

Subpart P—PROSPECTIVE PAYMENT FOR INPATIENT REHABILITATION HOSPITALS AND REHABILITATION UNITS

§412.600
Basis and scope of subpart.
§412.602
Definitions.
§412.604
Conditions for payment under the prospective payment system for inpatient rehabilitation facilities.
§412.606
Patient assessments.
§412.608
Patients' rights regarding the collection of patient assessment data.
§412.610
Assessment schedule.
§412.612
Coordination of the collection of patient assessment data.
§412.614
Transmission of patient assessment data.
§412.616
Release of information collected using the patient assessment instrument.
§412.618
Assessment process for interrupted stays.
§412.620
Patient classification system.
§412.622
Basis of payment.
§412.624
Methodology for calculating the Federal prospective payment rates.
§412.626
Transition period.
§412.628
Publication of the Federal prospective payment rates.
§412.630
Limitation on review.
§412.632
Method of payment under the inpatient rehabilitation facility prospective payment system.


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