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Diagnosis Related Groups (APR DRG) grouper; the APR DRG system classifies each inpatient stay based on information contained in the Medicaid inpatient claim, including diagnosis codes, procedure codes, discharge status codes, and patient characteristics;

(3) DRG relative weights are derived from an APR DRG national hospital-specific relative value (HSRV) weight set for the version of the grouper that is in place; the department may scale the DRG relative weight values to represent Medicaid claims experience for this state to achieve a case mix index of 1.0;

(4) average lengths of stay are derived from an APR DRG national weight set for the version of the grouper that is in place;

(5) a Healthcare Acquired Conditions (HAC) utility is used to remove HACs from consideration in an APR DRG assignment;

(6) the department may multiply DRG relative weights by policy adjustors based on patient age or the patient’s APR DRG assignment to increase or decrease reimbursement; each APR DRG is assigned to a service category determined by the department;

(7) the DRG base payment before the application of other payment adjustments is calculated as follows: DRG base rate * APR DRG relative weight * policy adjustor = DRG base payment;

(8) transfer adjustments that are based on uniform billing discharge status codes, as set out in the American Hospital Association’s Official UB-04 Data Specification Manual, 2024 edition, adopted by reference in 7 AAC 160.900(a), and that are based on length of stay, prorate payments as follows:

(A) transfer adjustments apply in cases where a patient is transferred to another hospital before completing the expected full course of treatment as determined by the national length of stay for the APR DRG assigned to a case;

(B) the transfer payment policy applies to the hospital making the transfer; the hospital receiving the patient is not subject to the transfer payment policy;

(C) APR DRGs that are specifically described to apply to transferred patients are exempt from transfer payment adjustments;

(D) in the transfer adjustment calculation, one day is added to the actual length of stay to reflect the higher costs of care that typically occur on the first day of an inpatient stay;

(E) the discharge status codes triggering a transfer payment are discharge status codes 02, 05, 62, 63, 65, 66, 82, 85, 90, 91, 93, and 94;

(F) if the actual length of stay plus one is less than the national average length of stay and the discharge status code on the claim is one specified by the department to trigger the transfer adjustment, the transfer adjustment calculation is as follows: