# 89 Ill. Adm. Code 1480.148.140: Section 148.140 Hospital Outpatient and Clinic Services

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URL: https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_140

## Section

- **Citation:** 89 Ill. Adm. Code 1480.148.140
- **Heading:** Section 148.140 Hospital Outpatient and Clinic Services
- **Jurisdiction:** Illinois
- **Kind:** Regulations
- **Status:** In force
- **Text as of:** August 14, 2026
- **Source:** Compiled text
- **Location:** Illinois Administrative Code / Title 89  /  / Part 1480  / Section 148.140 Hospital Outpatient and Clinic Services

## Text

Section 148
TITLE 89: SOCIAL SERVICES
CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES
SUBCHAPTER d: MEDICAL PROGRAMS
PART 148 HOSPITAL SERVICES
SECTION 148.140 HOSPITAL OUTPATIENT AND CLINIC SERVICES
Section 148.140  Hospital Outpatient and Clinic Services
Effective for dates of service on or after July 1, 2014,
unless another date is specified:
a)         Fee-For-Service
Professional Services Reimbursement. Effective for dates of service on or after
July 1, 2020, all fee-for-service hospital outpatient professional services
will be reimbursed in accordance with subsection (b)(1) except for end stage
renal disease treatment (ESRDT) services, as described in subsection (g).
b)         EAPG
PPS Reimbursement.  Reimbursement under EAPG PPS, described in subsection (c),
shall be all-inclusive for all services provided by the hospital, without
regard to the amount charged by a hospital.  Except as provided in subsection
(b)(3), no separate reimbursement will be made for ancillary services or the
services of hospital personnel.
1)         Outpatient
hospital services reimbursed through the EAPG PPS shall include:
A)        Surgical
services.
B)        Diagnostic
and therapeutic services.
C)        Emergency
department services.
D)        Observation
services.
E)        Psychiatric
treatment services.
2)         Excluded
from reimbursement under the EAPG PPS are outpatient hospital services
reimbursed pursuant to 59 Ill. Adm. Code 131 and 132, 77 Ill. Adm. Code 2090,
and Section 148.330 of this Part.
3)         As an
exception to the all-inclusive EAPG PPS rate, a separate professional claim may
be submitted under a physician's name and NPI for a physician who provided
direct patient care. For purposes of this subsection (b)(3), a physician means:
A)        A
physician salaried by the hospital
uant to 59 Ill. Adm. Code 131 and 132, 77 Ill. Adm. Code 2090,
and Section 148.330 of this Part.
3)         As an
exception to the all-inclusive EAPG PPS rate, a separate professional claim may
be submitted under a physician's name and NPI for a physician who provided
direct patient care. For purposes of this subsection (b)(3), a physician means:
A)        A
physician salaried by the hospital.  Physicians salaried by the hospital do not
include radiologists, pathologists, nurse practitioners, or certified
registered nurse anesthetists; no separate reimbursement will be allowed for those
providers.
B)        A
physician who is reimbursed by the hospital through a contractual arrangement
to provide direct patient care.
C)        A
group of physicians with a financial contract to provide emergency department
care.
4)         Effective
for dates of service on or after January 1, 2023, a general acute care hospital
that provides more than 500 outpatient psychiatric Medicaid services to persons
under 19 years of age in any calendar year prior to the rate year shall be paid
a $113 add-on payment. "Rate Year" means the calendar year beginning
January 1
st
, with the first rate year being calendar year 2023.
c)         EAPG
PPS Payment.  The reimbursement to hospitals for outpatient services provided
on the same day shall be the product, rounded to the nearest hundredth, of the
following:
1)         The
EAPG weighting factor of the EAPG to which the service was assigned by the EAPG
grouper.
2)         The
EAPG conversion factor, based on the sum of:
A)        The
product, rounded to the nearest hundredth, of:
i)          the
labor-related share;
ii)         the
Medicare IPPS wage index; and
iii)        the
applicable EAPG standardized amount.
B)        The
product, rounded to the nearest hundredth, of:
i)          non-labor
share; and
ii)         the
applicable EAPG standardized amount.
3)         The
applicable consolidation factor.
4)         The
applicable packaging factor
est hundredth, of:
i)          the
labor-related share;
ii)         the
Medicare IPPS wage index; and
iii)        the
applicable EAPG standardized amount.
B)        The
product, rounded to the nearest hundredth, of:
i)          non-labor
share; and
ii)         the
applicable EAPG standardized amount.
3)         The
applicable consolidation factor.
4)         The
applicable packaging factor.
5)         The
applicable discounting factor.
6)         The
applicable policy adjustment factors, as defined in subsection (f), for which
the service qualifies.
d)         EAPG Standardized
Amount.  The standardized amount established by the Department as the basis for
EAPG conversion factor differs based on the provider type:
1)         County-operated
Large Public Hospital EAPG Standardized Amount.  For a large public hospital,
as defined in Section 148.25(a)(1), the EAPG standardized amount is determined
in Section 148.160.
2)         University-operated
Large Public Hospital EAPG Standardized Amount.  For a large public hospital,
as defined in Section 148.25(a)(2), the EAPG standardized amount is determined
in Section 148.170.
3)         Critical
Access Hospital EAPG Standardized Amount.
A)        For
critical access hospitals, as defined in Section 148.25(g), the EAPG
standardized amounts are determined separately for each critical access
hospital such that simulated EAPG payments using outpatient base period paid
claim data plus payments as defined in Section 148.423 net of tax costs are
equal to the estimated costs of outpatient base period claims data with a rate
year cost inflation factor applied.
B)        Effective
January 1, 2024, simulated EAPG payments using outpatient base period paid
claim data are calculated to be budget neutral to simulated payments using the
rates in effect as of December 31, 2023. The budget neutral hospital specific
EAPG rates are then increased by 10%, except as limited by the federally
required upper payment limit (UPL)
year cost inflation factor applied.
B)        Effective
January 1, 2024, simulated EAPG payments using outpatient base period paid
claim data are calculated to be budget neutral to simulated payments using the
rates in effect as of December 31, 2023. The budget neutral hospital specific
EAPG rates are then increased by 10%, except as limited by the federally
required upper payment limit (UPL).
4)         Acute
EAPG Standardized Amount
A)        Qualifying
Criteria.  General acute hospitals and freestanding emergency centers as
defined in 148.25(e) excluding providers in subsections (d)(1) through (d)(3),
freestanding psychiatric hospitals, psychiatric distinct part units,
freestanding rehabilitation hospitals, and rehabilitation distinct part units.
B)        Effective
January 1, 2024, the acute EAPG standardized amount is based on a single
statewide amount determined such that simulated EAPG allowed amount using
general acute hospital outpatient base period paid claims data, is equal to the
sum of general acute hospital base period paid claims data allowed amount
increased by 10%. For subsequent years, acute EAPG standardized amount is based
on a single statewide amount determined such that simulated EAPG allowed amount
using general acute hospital outpatient base period paid claims data is equal
to the sum of general acute hospital base period paid claims data allowed
amount
.
5)         Psychiatric
EAPG Standardized Amount
A)        Qualifying
Criteria.  Freestanding psychiatric hospitals and psychiatric distinct part
units
d
on a single statewide amount determined such that simulated EAPG allowed amount
using general acute hospital outpatient base period paid claims data is equal
to the sum of general acute hospital base period paid claims data allowed
amount
.
5)         Psychiatric
EAPG Standardized Amount
A)        Qualifying
Criteria.  Freestanding psychiatric hospitals and psychiatric distinct part
units.
B)        Effective
January 1, 2024, the psychiatric EAPG standardized amount is based on a single
statewide amount, determined such that simulated EAPG allowed amount, using
freestanding psychiatric hospitals and psychiatric distinct part units
outpatient base period paid claims data, is approximately equal to the sum of
the freestanding psychiatric hospitals and psychiatric distinct part units
outpatient base period paid claims data allowed amount increased by 10%.  For
subsequent years, psychiatric EAPG standardized amount is based on a single
statewide amount determined such that simulated EAPG allowed amount using
freestanding psychiatric hospitals and psychiatric distinct part units
outpatient base period paid claims data, is approximately equal to the sum of
the freestanding psychiatric hospitals and psychiatric distinct part units
outpatient base period paid claims data allowed amount.
6)         Rehabilitation
EAPG Standardized Amount
A)        Qualifying
Criteria.  Freestanding rehabilitation hospitals and rehabilitation distinct
part units.
B)        The
rehabilitation EAPG standardized amount is based on a single statewide amount,
determined such that simulated EAPG payments using freestanding rehabilitation
hospitals and rehabilitation distinct part units outpatient base period paid
claims data, results in allowed amount approximately equal to freestanding
rehabilitation hospitals and rehabilitation distinct part units outpatient base
period paid claims data allowed amount increased by 10%
n a single statewide amount,
determined such that simulated EAPG payments using freestanding rehabilitation
hospitals and rehabilitation distinct part units outpatient base period paid
claims data, results in allowed amount approximately equal to freestanding
rehabilitation hospitals and rehabilitation distinct part units outpatient base
period paid claims data allowed amount increased by 10%.  For subsequent years,
simulated EAPG payments using freestanding rehabilitation hospitals and
rehabilitation distinct part units outpatient base period paid claims data,
results in allowed amount approximately equal to freestanding rehabilitation
hospitals and rehabilitation distinct part units outpatient base period paid
claims data allowed amount.
7)         Ambulatory
Surgical Treatment Center (ASTC) EAPG Standardized Amount.  For ASTC's, as
defined in 89 Ill. Adm. Code 146.105, the EAPG standardized amount is
determined such that simulated EAPG payments using outpatient base period paid
claims data are equal to reported payments of outpatient base period paid
claims data as contained in the Department's claims data warehouse.
8)         Out-of-State
Non-Cost Reporting Hospital EAPG Standardized Amount.  For non-cost reporting
hospitals, the EAPG standardized amount is $362.32, and is not wage adjusted.
e)         Discounting
Factor.  The applicable discounting factor is based on the discounting flags
designated by the EAPG grouper under default EAPG settings:
1)         The
discounting factor will be 1.0000, if the following criteria are met:
A)        The
service has not been designated with a Bilateral Procedure Discounting flag,
Multiple Procedure Discounting flag, Repeat Ancillary Discounting flag or
Terminated Procedure Discounting flag by the EAPG grouper under default EAPG
settings; or
B)        The
service has not been designated with a Bilateral Procedure Discounting flag and
has been designated with a Multiple Procedure Discounting flag by the EAPG
grouper under default EAPG setting
rocedure Discounting flag,
Multiple Procedure Discounting flag, Repeat Ancillary Discounting flag or
Terminated Procedure Discounting flag by the EAPG grouper under default EAPG
settings; or
B)        The
service has not been designated with a Bilateral Procedure Discounting flag and
has been designated with a Multiple Procedure Discounting flag by the EAPG
grouper under default EAPG settings and the service has the highest EAPG
weighting factor among other services with a Multiple Procedure Discounting
flag provided on the same day.
2)         The
discounting factor will be 0.5000 if the following criteria are met:
A)        The
service has been designated with a Multiple Procedure Discounting flag, Repeat
Ancillary Discounting flag or Terminated Procedure Discounting flag by the EAPG
grouper under default EAPG settings; and if the Multiple Procedure Discounting
flag is present, the service does not have the highest EAPG weighting factor
among other services with a Multiple Procedure Discounting flag provided on the
same day; and
B)        The
service has not been designated with a Bilateral Procedure Discounting flag by
the EAPG grouper under default EAPG settings.
3)         The
discounting factor will be 0.7500 if the following criteria are met:
A)        The
service has been designated with a Bilateral Procedure Discounting flag by the
EAPG grouper under default EAPG settings; and
B)        The
service has been designated with a Multiple Procedure Discounting flag, the
Repeat Ancillary Discounting flag or Terminated Procedure Discounting flag by
the EAPG grouper under default EAPG settings; and if the Multiple Procedure
Discounting flag is present, the service does not have the highest EAPG
weighting factor among other services with a Multiple Procedure Discounting
flag provided on the same day
been designated with a Multiple Procedure Discounting flag, the
Repeat Ancillary Discounting flag or Terminated Procedure Discounting flag by
the EAPG grouper under default EAPG settings; and if the Multiple Procedure
Discounting flag is present, the service does not have the highest EAPG
weighting factor among other services with a Multiple Procedure Discounting
flag provided on the same day.
4)         The
discounting factor will be 1.5000 if the following criteria are met:
A)        The
service has been designated with a Bilateral Procedure Discounting flag by the
EAPG grouper under default EAPG settings; and
B)        The
service has not been designated with a Multiple Procedure Discounting flag, the
Repeat Ancillary Discounting flag or Terminated Procedure Discounting flag by
the EAPG grouper under default EAPG settings; or if the Multiple Procedure
Discounting flag is present, the service has the highest EAPG weighting factor
among other services with a Multiple Procedure Discounting flag provided on the
same day.
f)         Policy
Adjustments.  Claims for services by providers that meet certain criteria shall
qualify for further adjustments to payment.  If a claim qualifies for more than
one policy adjustment, then the EAPG PPS payment will be multiplied by both
factors.
1)         Crossover
Adjustment Factor
A)        Acute
EAPG standardized amounts, as defined in subsection (d)(4), shall be reduced by
a Crossover Adjustment factor such that:
i)          The
absolute value of the total simulated payment reduction that occurs when
applying the Crossover Adjustment Factor to simulated EAPG payments, including
Policy Adjustments, using general acute hospital outpatient base period paid
claims data, is equal to the amount derived in subsection (f)(1)(A)(ii):
ii)         The
difference of total simulated EAPG payments using general acute hospital
outpatient crossover paid claims data, and general acute hospital outpatient
crossover paid claims data total reported Medicaid net liabil
yments, including
Policy Adjustments, using general acute hospital outpatient base period paid
claims data, is equal to the amount derived in subsection (f)(1)(A)(ii):
ii)         The
difference of total simulated EAPG payments using general acute hospital
outpatient crossover paid claims data, and general acute hospital outpatient
crossover paid claims data total reported Medicaid net liability.
B)        Crossover
Adjustment Factor effective SFY 2015 and 2016 is 0.98912.  Effective July 1,
2018, the Crossover Adjustment Factor is defined in (f)(1)(A)(i).
2)         If a
claim does not qualify for a Policy Adjustment described in subsection (f)(3)
or (f)(4), the policy adjustment factor is 1.0.
3)         High Outpatient Volume Hospital
Effective July 1, 2018
A)        High
Outpatient Volume Hospital is defined as:
i)          an Illinois
hospital for which the high outpatient volume is at least one and one-half
standard deviations above the mean regional high outpatient volume;
ii)         an Illinois
hospital for which the high outpatient volume is at least one and one-half
standard deviations above the mean statewide high outpatient volume;
iii)        an Illinois
Safety-Net Hospital as defined in Section 149.100; or
iv)        an Illinois
Small Public Hospital, which is defined as any publicly owned hospital that is
not a large public hospital as defined in Section 148.25.
B)        Policy
adjustment factor is set:
i)          For
acute care claims such that total expenditures on qualifying claims less the
rate reductions defined in P.A. 97-0689 is increased by $79.2 million more than
base period qualifying claims allowed amount.
ii)         For
non-acute care claims to equal the factor in place prior to July 1, 2018
ublic hospital as defined in Section 148.25.
B)        Policy
adjustment factor is set:
i)          For
acute care claims such that total expenditures on qualifying claims less the
rate reductions defined in P.A. 97-0689 is increased by $79.2 million more than
base period qualifying claims allowed amount.
ii)         For
non-acute care claims to equal the factor in place prior to July 1, 2018.
4)         For
High Outpatient Volume Hospitals effective on or after January 1, 2023:
A)        The
hospital is a High Outpatient Volume hospital, defined as:
i)          an Illinois
hospital for which the high outpatient volume is at least two times above the
mean regional high outpatient volume;
ii)         an Illinois
hospital for which the high outpatient volume is at least one and one-half
standard deviations above the mean statewide high outpatient volume;
iii)        an
Illinois Safety-Net Hospital as defined in 89 Ill. Adm. Code 149.100(f)(4); or
iv)        an
Illinois Small Public Hospital, which is defined as any publicly owned hospital
that is not a large public hospital as defined in 89 Ill. Adm. Code 148.25.
B)        Upon
any update of EAPG groupers, the policy adjustment factor shall be set so that
expenditures attributed to the adjustment factor on claims in the base period
is equal to the expenditures attributed to the adjustment factor on the same
claims under the new grouper.
g)         Payment
for outpatient end-stage renal disease treatment (ESRDT) services provided
pursuant to Section 148.40(b) shall be made at the Department's payment rates,
as follows:
1)         For
outpatient services or home dialysis treatments provided pursuant to Section
148.40(c)(2) or (c)(3), the Department will reimburse hospitals and clinics for
ESRDT services at a rate that will reimburse the provider for the dialysis
treatment and all related supplies and equipment, as defined in 42 CFR 405.2124
and 413.170 (2010)
e at the Department's payment rates,
as follows:
1)         For
outpatient services or home dialysis treatments provided pursuant to Section
148.40(c)(2) or (c)(3), the Department will reimburse hospitals and clinics for
ESRDT services at a rate that will reimburse the provider for the dialysis
treatment and all related supplies and equipment, as defined in 42 CFR 405.2124
and 413.170 (2010).  This rate will be the rate established by Medicare
pursuant to 42 CFR 405.2124 and 413.170 (2010).
2)         Payment
for Non-routine Services.  For services that are provided during outpatient or
home dialysis treatment pursuant to Section 148.40(c)(2) or (c)(3), but are not
defined as a routine service under 42 CFR 405.2163 (1994), separate payment
will be made to independent laboratories, pharmacies, and medical supply
providers pursuant to 89 Ill. Adm. Code 140.430 through 140.434, 140.440
through 140.50, and 140.75 through 140.481, respectively.
3)         Payment
for physician services relating to ESRDT will be made separately to physicians,
pursuant to 89 Ill. Adm. Code 140.400.
4)         Effective
with dates of service July 1, 2013, hospital and freestanding chronic dialysis
centers will receive an add-on payment of $60 per treatment day to the rate
described in subsection (g)(1) for outpatient renal dialysis treatments or home
dialysis treatments provided to Medicaid recipients under Title XIX of the
Social Security Act, excluding services for individuals eligible for Medicare
under Title XVIII of that Act (Medicaid/Medicare crossovers) and excluding
services provided under Subpart D:  State Chronic Renal Disease Program, as
defined in Sections 148.600 through 148.640.
h)         Updates
to EAPG PPS Reimbursement.  The Department may annually review the components
listed in subsection (c) and make adjustments as needed. Grouper shall be
updated at least triennially and no more frequently than annually
id/Medicare crossovers) and excluding
services provided under Subpart D:  State Chronic Renal Disease Program, as
defined in Sections 148.600 through 148.640.
h)         Updates
to EAPG PPS Reimbursement.  The Department may annually review the components
listed in subsection (c) and make adjustments as needed. Grouper shall be
updated at least triennially and no more frequently than annually.
i)          Definitions, as used in
this Section:
"Aggregate ancillary
cost-to-charge ratio" means the ratio of each hospital's total ancillary
costs and charges reported in the Medicare cost report, excluding special
purpose cost centers and the ambulance cost center, for the cost reporting
period matching the outpatient base period claims data.  Aggregate ancillary
cost-to-charge ratios applied to SFY 2011 outpatient base period claims data
will be based on fiscal year ending 2011 Medicare cost report data.
"Allowed amounts" means
the calculated fee schedule amount prior to any adjustment for secondary payer
amounts for outpatient base period claims data.  If volume in base period data
is estimated to differ from rate year volume, then completion factors are
applied.
"Consolidation factor"
means a factor of 0 percent applicable for services designated with a Same
Procedure Consolidation flag or Clinical Procedure Consolidation flag by the
EAPG grouper under default EAPG settings.
"Default EAPG settings"
means the default EAPG grouper options in 3M's Core Grouping Software for each
EAPG grouper version, except where the Department made adjustments.
"Detailed ancillary cost-to-charge
ratios" means for each standardized ancillary Medicare cost-center
cost-to-charge ratios for each hospital calculated by dividing total costs in
Worksheet C, Part 1, Column 5 and Worksheet B, Part 1, Columns 21 and 22 by
total charges for each standardized ancillary Medicare cost center in Worksheet
C, Part 1, Columns 6 and 7
the Department made adjustments.
"Detailed ancillary cost-to-charge
ratios" means for each standardized ancillary Medicare cost-center
cost-to-charge ratios for each hospital calculated by dividing total costs in
Worksheet C, Part 1, Column 5 and Worksheet B, Part 1, Columns 21 and 22 by
total charges for each standardized ancillary Medicare cost center in Worksheet
C, Part 1, Columns 6 and 7.  For all hospitals missing Worksheet C, Part 1,
Column 5 data, use Worksheet C, Part 1, Column 3 data.  Use aggregate ancillary
cost-to-charge ratios as a default when a cost-center specific cost-to-charge
ratio is not available or the claim revenue code is all-inclusive ancillary.
"EAPG" means Enhanced
Ambulatory Patient Groups, as defined in the EAPG grouper, which is a patient
classification system designed to explain the amount and type of resources used
in an ambulatory visit.  Services provided in each EAPG have similar clinical
characteristics and similar resource use and cost.
"EAPG grouper" means the
version of the EAPG software, distributed by 3M Health Information Systems, being
used by the Department for pricing hospital outpatient services in accordance
with 305 ILCS 5/14-12(a), (b) and (e).
"EAPG PPS" means the
EAPG prospective payment system as described in this Section.
"EAPG weighting factor"
means, for each EAPG, the product, rounded to the nearest ten-thousandth, of:
the national weighting factor, as
published by 3M Health Information Systems for the EAPG grouper; and
the Illinois
experience adjustment.
"Estimated
cost of outpatient base period claims data" means:
Prior to July 1,
2018, the product of:
outpatient base
period paid claims data total covered charges;
the critical access hospital's
aggregate ancillary cost-to-charge ratio; and
a rate year cost
inflation factor
ng factor, as
published by 3M Health Information Systems for the EAPG grouper; and
the Illinois
experience adjustment.
"Estimated
cost of outpatient base period claims data" means:
Prior to July 1,
2018, the product of:
outpatient base
period paid claims data total covered charges;
the critical access hospital's
aggregate ancillary cost-to-charge ratio; and
a rate year cost
inflation factor.
Effective July
1, 2018, the product of:
Outpatient base period claims data
total covered charges;
The critical access hospital's
detailed ancillary cost-to-charge ratios; and
A rate year cost inflation factor.
"High outpatient volume"
means the number paid outpatient claims described in subsection (b)(1) provided
during the high volume outpatient base period paid claims data.
"High volume outpatient base
period paid claims data" means:
Prior to July 1, 2018, SFY 2011
outpatient Medicaid fee-for-service paid claims data, excluding Medicare dual
eligible claims, renal dialysis claims, and therapy claims, for EAPG PPS
payment for services provided in SFY 2015 and 2016.  For subsequent dates of
service, the term means the SFY ending 30 months prior to the beginning of the
calendar year during which the service is provided.
Effective July 1, 2018, SFY 2015
outpatient Medicaid fee-for-service paid claims data and completed MCO
encounter claims data, excluding Medicare dual eligible claims, renal dialysis
claims, and therapy claims, for EAPG PPS payment for services provided in SFY
2019 and 2020; for subsequent dates of service, the most recently available
adjudicated 12 months of outpatient paid claims data to be identified by the
Department
15
outpatient Medicaid fee-for-service paid claims data and completed MCO
encounter claims data, excluding Medicare dual eligible claims, renal dialysis
claims, and therapy claims, for EAPG PPS payment for services provided in SFY
2019 and 2020; for subsequent dates of service, the most recently available
adjudicated 12 months of outpatient paid claims data to be identified by the
Department.
"Illinois experience
adjustment" means, for the calendar year beginning January 1, 2014, a
factor of 1.0; for subsequent calendar years, means the factor applied to 3M
EAPG national weighting factors when updating EAPG grouper versions determined
such that the arithmetic mean EAPG weighting factor under the new EAPG grouper
version is equal to the arithmetic mean EAPG weighting factor under the prior
EAPG grouper version using outpatient base period claims data.
"In-state" means all:
Illinois
hospitals; and
out-of-state hospitals that are
designated a level I pediatric trauma center or a level I trauma center by the
Illinois Department of Public Health as of December 1, 2017.
"Labor-related share"
means that portion of the statewide standardized amount that is allocated in
the EAPG PPS methodology to reimburse the costs associated with personnel.  The
labor-related share for a hospital is 0.60.
"Mean regional high
outpatient volume" means the quotient, rounded to the nearest tenth,
resulting from the number of paid outpatient services described in subsections
(b)(1)(A) through (D), provided by hospitals within a region, based on
outpatient base period paid claims data.
"Mean statewide high
outpatient volume" means the quotient, rounded to the nearest tenth,
resulting from the number of paid outpatient services described in subsections
ent, rounded to the nearest tenth,
resulting from the number of paid outpatient services described in subsections
(b)(1)(A) through (D), provided by hospitals within a region, based on
outpatient base period paid claims data.
"Mean statewide high
outpatient volume" means the quotient, rounded to the nearest tenth,
resulting from the number of paid outpatient services described in subsections
(b)(1)(A) through (D), provided by hospitals within the state, based on
outpatient base period paid claims data.
"Medicare IPPS wage
index" means for in-state providers and out-of-state Illinois Medicaid
cost reporting providers, the wage index used for inpatient reimbursement as
described in 89 Ill. Adm. Code 149.100.  For out-of-state non‑cost reporting
providers, the wage index used to adjust the EAPG standardized amount shall be
a factor of 1.0.
"Non-labor share" means
the difference resulting from the labor-related share being subtracted from
1.0.
"Outpatient base period paid
claims data" means:
Prior to July 1, 2018, SFY 2011
outpatient Medicaid fee-for-service paid claims data, excluding Medicare dual
eligible claims, renal dialysis claims, and therapy claims, for EAPG PPS
payment for services provided in SFY 2015, 2016 and 2017;
Effective July 1, 2018 through
June 30, 2020, for in-state SFY 2015 outpatient Medicaid fee-for-service paid
claims data and completed MCO encounter claims data, excluding Medicare dual
eligible claims, renal dialysis claims, and therapy claims, for EAPG PPS
payment for services provided in SFY 2019 and 2020.
Effective July 1, 2020:
SFY 2017, or the most recent 12
months of available data as identified by the Department, outpatient Medicaid
claims data, for in-state hospitals that are not large public hospitals; and
SFY 2017 and 2018, or the most
recent 12 months of available data as identified by the Department, outpatient
Medicaid claims data for out-of-state hospitals
vided in SFY 2019 and 2020.
Effective July 1, 2020:
SFY 2017, or the most recent 12
months of available data as identified by the Department, outpatient Medicaid
claims data, for in-state hospitals that are not large public hospitals; and
SFY 2017 and 2018, or the most
recent 12 months of available data as identified by the Department, outpatient
Medicaid claims data for out-of-state hospitals.
"Outpatient crossover paid
claims data" means:
Outpatient Medicaid/Medicare dual
eligible fee-for-service and managed care paid claims data, excluding renal
dialysis claims and therapy claims, with dates of service from the same time
period as outpatient base period claims data.
"Packaging factor" means
a factor of 0 percent applicable for services designated with a Packaging flag
by the EAPG grouper under default EAPG settings plus EAPG 430 (Class I
Chemotherapy Drugs), EAPG 435 (Class I Pharmacotherapy), EAPG 495 (Minor
Chemotherapy Drugs), EAPG 496 (Minor Pharmacotherapy), and EAPGs 1001-1020 (Durable
Medical Equipment Level 1-20), and non-covered revenue codes defined in the
Handbook for Hospital Services.
"Rate year cost inflation
factor" means the cost inflation from the midpoint of the outpatient base
period paid claims data to the midpoint of the rate year based on changes in
Centers for Medicare and Medicaid Services (CMMS) input price index levels.
For critical access hospital rates effective SFY 2015, the rate year cost
inflation factor will be based on changes in CMMS input price index levels from
the midpoint of SFY 2011 to SFY 2015.
"Region" means, for a
given hospital, the rate region, as defined in 89 Ill. Adm. Code
140.Table J
, within
which the hospital is located.
"SFY" means State fiscal
year.
"Total covered charges"
means the amount entered for revenue code 001 in column 53 (Total Charges) on
the Uniform Billing Form (form CMMS 1450), or one of its electronic transaction
equivalents.
j)          Supplemental
Payment
ion" means, for a
given hospital, the rate region, as defined in 89 Ill. Adm. Code
140.Table J
, within
which the hospital is located.
"SFY" means State fiscal
year.
"Total covered charges"
means the amount entered for revenue code 001 in column 53 (Total Charges) on
the Uniform Billing Form (form CMMS 1450), or one of its electronic transaction
equivalents.
j)          Supplemental
Payment. A one-time supplemental payment will be made to a critical access
hospital (which is an Illinois hospital designated by the Illinois Department
of Public Health in accordance with 42 CFR 485 Subpart F) for outpatient
discharges occurring in SFY 2019 for which the outpatient claims were priced
and paid under the methodology in subsection (d)(3)(A). The amount of the
supplemental payment will be equal to the difference of:
1)         The
payment amount of each claim calculated using the critical access hospital EAPG
standardized amount set to equal a 23% increase in simulated EAPG payments
using base period paid claims data set forth in subsection (d)(3)(B); and
2)         The
payment amount of each claim calculated using the critical access hospital EAPG
standardized amount in effect on July 1, 2018.

## Nearby sections

- [89 Ill. Adm. Code 1480.148.105 Section 148.105  Reimbursement Methodologies for Inpatient Rehabilitation Services](https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_105.md)
- [89 Ill. Adm. Code 1480.148.110 Section 148.110  Reimbursement Methodologies for Inpatient Psychiatric Services](https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_110.md)
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- [89 Ill. Adm. Code 1480.148.116 Section 148.116  Reimbursement Methodologies for Children's Specialty Hospitals](https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_116.md)
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- [89 Ill. Adm. Code 1480.148.140 Section 148.140  Hospital Outpatient and Clinic Services](https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_140.md)
- [89 Ill. Adm. Code 1480.148.200 Section 148.200  Critical Access Hospital OB and Other Treatment Services Payment (CAHOOTS)](https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_200.md)
- [89 Ill. Adm. Code 1480.148.240 Section 148.240  Utilization Review and Furnishing of Inpatient Hospital Services Directly or Under Arrangements](https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_240.md)
- [89 Ill. Adm. Code 1480.148.390 Section 148.390  Hearings](https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_390.md)
- [89 Ill. Adm. Code 1480.148.405 Section 148.405  Graduate Medical Education (GME) Payment](https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_405.md)
- [89 Ill. Adm. Code 1480.148.406 Section 148.406  Graduate Medical Education (GME) Payment for Large Public Hospitals](https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_406.md)
- [89 Ill. Adm. Code 1480.148.407 Section 148.407  Medicaid High Volume Hospital Access Payment (Repealed)](https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_407.md)
- [89 Ill. Adm. Code 1480.148.422 Section 148.422  Safety Net Obstetrical Payment](https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_422.md)

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Source: Frix Law Library, https://www.frixlaw.com/law-library/statutes/STATE_IL_IAC_T89_P1480_S148_140. Check the current official text before relying on it. Not legal advice.