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their last hospital or Medicare approved SNF. c. An individual who goes from care in a nursing facility which is not Medicare approved SNF to a hospital may establish a new benefit period. 2. Diagnosis Related Groups (DRG) Reimbursement. a. A set fee, based on the hospital's classification under Medicare and the patient's diagnosis, is incurred on the date of admission. (1) The entire Medicare Part A deductible is due on the date of admission provided a new hospital benefit period has begun. (2) When splitting the patient's PML between the hospital and the nursing facility, use only the Part A deductible for the portion assigned to the hospital instead of the actual hospital charges or per diem. Request the amount the a/b owes to the hospital. The PML is not changing, only to whom it is assigned.

b. If the patient is not admitted under DRG, they are responsible for actual daily hospital charges until the Medicare Part A deductible is met. (1) Use the actual daily charges at the Medicaid per diem, until the Medicare Part A deductible is met when splitting the PML.

(2) If the amount of PML not already owed to the NF for the month is less than the Part A deductible, assign that amount as PML to the hospital.

3. From Medicare approved SNF to the hospital, the a/b may remain in the same benefit period with no responsibility for the Part A deductible, but with the possibility of co-insurance responsibility.

4. Be sure to involve the hospital business office and/or NF since their knowledge of Medicare coverage assists in determining the a/b’s responsibility to the hospital.

XV. PRIOR APPROVALS (FL-2 AND MR-2) Certain types of care require prior approval by DHB. The FL-2/MR-2 are the Long- Term Care Services and Mental Health Services prior approval forms which give a summary of the patient's medical requirements. This section instructs you on the prior approval process.

A. Levels Which Require Prior Approval 1. Nursing facility level of care, including inappropriate level and swing beds in a general hospital. Care at this level also requires the Pre- Admission Screen and Annual Resident Review (PASARR) to be completed prior to EDS/Murdoch Center approval (See Table iii). The PASARR process assures that persons with serious mental illness, mental retardation, and/or conditions related to mental retardation receive appropriate placement and services. Docusign Envelope ID: 950E9248-29CC-8930-81BC-BCEC667EB493