**PROPOSED RULES**

**SOCIAL AND HEALTH SERVICES**

(Health and Recovery Services Administration)

Original Notice.

Preproposal statement of inquiry was filed as WSR 06-22-054.

Title of Rule and Other Identifying Information: **Part 4
of 6;** amending WAC 388-550-3700 DRG high-cost and low-cost
outliers.

Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on June 5, 2007, at 10:00 a.m.

Date of Intended Adoption: Not earlier than June 6, 2007.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail schilse@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m. on June 5, 2007.

Assistance for Persons with Disabilities: Contact Stephanie Schiller by June 1, 2007, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The proposed rule describes how the department pays inpatient hospital claims for dates of admission on and after August 1, 2007. The proposed rule reflects recommendations made in the navigant study and supported by the state legislature. In addition, the proposed rules replace "medical assistance administration (MAA)" with "the department," and update and clarify other language.

Reasons Supporting Proposal: In 2005, ESSB 6090 recommended that a study be done by navigant to look at the department's inpatient hospital payment system and include recommendations on the design. This rule is written to incorporate the results of the navigant study into rule, and to update information on the department's hospital coverage, rate-setting, and payment processes. At the same time and for the same reasons, the department is proposing rule making to reflect changes and new sections in chapter 388-550 WAC.

Statutory Authority for Adoption: RCW 74.08.090 and 74.09.500.

Statute Being Implemented: RCW 74.08.090 and 74.09.500.

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of social and health services, governmental.

Name of Agency Personnel Responsible for Drafting: Kathy Sayre, P.O. Box 45504, Olympia, WA 98504-5504, (360) 725-1342; Implementation and Enforcement: Larry Linn, P.O. Box 45502, Olympia, WA 98504-5502, (360) 725-1856.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has determined that the proposed rule will not create more than minor costs for affected small businesses.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Larry Linn, P.O. Box 45502, Olympia, WA 98504-5502, phone (360) 725-1856, fax (360) 753-9152, e-mail linnld@dshs.wa.gov.

April 26, 2007

Stephanie E. Schiller

Rules Coordinator

3866.1 (1) __For dates of admission before August 1, 2007, a__
__m__edicaid or state-administered claim qualifies as a DRG
high-cost outlier when:

(a) The client's admission date on the claim is before January 1, 2001, the stay did not meet the definition of "administrative day," and the allowed charges exceed:

(i) A threshold of twenty-eight thousand dollars; and

(ii) A threshold of three times the applicable DRG payment amount.

(b) The client's admission date on the claim is January 1, 2001, or after, the stay did not meet the definition of "administrative day," and the allowed charges exceed:

(i) A threshold of thirty-three thousand dollars; and

(ii) A threshold of three times the applicable DRG payment amount.

(2) __For dates of admission before August 1, 2007, i__f the
claim qualifies as a DRG high-cost outlier, the high-cost
outlier threshold, for payment purposes, is the amount in
subsection (1)(a)(i) or (ii), whichever is greater, for an
admission date before January 1, 2001; or subsection (1)(b)(i)
or (ii), whichever is greater, for an admission date January
1, 2001 or after.

(3) __For dates of admission before August 1, 2007, t__he
department determines payment for __m__edicaid claims that qualify
as DRG high-cost outliers as follows:

(a) All qualifying claims, except for claims in psychiatric DRGs 424-432 and in-state children's hospitals, are paid seventy-five percent of the allowed charges above the outlier threshold determined in subsection (2) of this section, multiplied by the hospital's RCC rate, plus the applicable DRG payment.

(b) In-state children's hospitals are paid eighty-five percent of the allowed charges above the outlier threshold determined in subsection (2) of this section, multiplied by the hospital's RCC rate, plus the applicable DRG payment.

(c) Psychiatric DRG high-cost outliers for DRGs 424-432 are paid one hundred percent of the allowed charges above the outlier threshold determined in subsection (2) of this section, multiplied by the hospital's RCC rate, plus the applicable DRG payment.

__Three examples for DRG high-cost outlier claim
qualification and payment calculation (admission dates are
January 1, 2001, or after, and before August 1, 2007).__

Examples for DRG high-cost outlier claim qualification and payment calculation (admission dates are January 1, 2001, or after). | |||||||||

Allowed Charges | Applicable DRG Payment | Three times App. DRG Payment | Allowed Charges > $33,000? | Allowed
Charges > Three times App. DRG Payment? |
DRG High-Cost Outlier Payment | Hospital's Individual RCC Rate | |||

$17,000 | $5,000 | $15,000 | No | Yes | N/A | 64% | |||

*33,500 | 5,000 | 15,000 | Yes | Yes | **$5,240 | 64% | |||

10,740 | 35,377 | 106,131 | No | No | N/A | 64% |

Medicaid Payment calculation example for allowed charges of: |
Nonpsych DRGs/Nonin-state children's hospital (RCC is 64%) | |

*$33,500 | Allowed charges | |

- $33,000 $ 500 |
The greater amount of 3 x app. DRG pymt ($15,000) or $33,000 | |

x 48% | 75% of allowed charges x hospital RCC rate (nonpsych DRGs/nonin-state children's) (75% x 64% = 48%) | |

$ 240 | Outlier portion | |

+ $ 5,000 | Applicable DRG payment | |

**$ 5,240 | Outlier payment |

(4) __For dates of admission before August 1, 2007,__ DRG
high-cost outliers for state-administered programs are paid
according to WAC 388-550-4800.

(5) ((~~A~~)) __For dates of admission before August 1, 2007, a
m__edicaid or state-administered claim qualifies as a DRG
low-cost outlier if:

(a) The client's admission date on the claim is before January 1, 2001, and the allowed charges are:

(i) Less than ten percent of the applicable DRG payment; or

(ii) Less than four hundred dollars.

(b) The client's admission date on the claim is January 1, 2001, or after, and the allowed charges are:

(i) Less than ten percent of the applicable DRG payment; or

(ii) Less than four hundred fifty dollars.

(6) If the claim qualifies as a DRG low-cost outlier:

(a) For an admission date before January 1, 2001, the low-cost outlier amount is the amount in subsection (5)(a)(i) or (ii), whichever is greater; or

(b) For an admission date on January 1, 2001, or after, the low-cost outlier amount is the amount in subsection (5)(b)(i) or (ii), whichever is greater.

(7) __For dates of admission before August 1, 2007, t__he
department determines payment for a Medicaid claim that
qualifies as a DRG low-cost outlier by multiplying the allowed
charges for each claim by the hospital's RCC rate.

(8) __For dates of admission before August 1, 2007,__ DRG
low-cost outliers for state-administered programs are paid
according to WAC 388-550-4800.

(9) __For dates of admission before August 1, 2007 t__he
department makes day outlier payments to hospitals in
accordance with section 1923 (a)(2)(C) of the Social Security
Act, for clients who have exceptionally long stays that do not
reach DRG high-cost outlier status. A hospital is eligible
for the day outlier payment if it meets all of the following
criteria:

(a) The hospital is a disproportionate share hospital (DSH) and the client served is under age six, or the hospital may not be a DSH hospital but the client served is a child under age one;

(b) The payment methodology for the admission is DRG;

(c) The allowed charges for the hospitalization are less than the DRG high-cost outlier threshold as defined in subsection (2) of this section; and

(d) The client's length of stay exceeds the day outlier threshold for the applicable DRG payment amount. The day outlier threshold is defined as the number of days in an average length of stay for a discharge (for an applicable DRG payment), plus twenty days.

(10) __For dates of admission before August 1, 2007 t__he
department bases the day outlier payment on the number of days
that exceed the day outlier threshold, multiplied by the
administrative day rate.

(11) __For dates of admission before August 1, 2007, t__he
department's total payment for day outlier claims is the
applicable DRG payment plus the day outlier or administrative
days payment.

(12) __For dates of admission before August 1, 2007, a__
client's outlier claim is either a day outlier or a high-cost
outlier, but not both.

__(13) For dates of admission on and after August 1, 2007,
the department does not identify a claim as a low cost outlier
or day outlier. Instead, these claims are processed using the
applicable payment method described in this chapter. The
department may review claims with very low costs.__

__ (14) For dates of admission on and after August 1, 2007,
the department allows a high outlier payment for claims paid
using the DRG payment method when high outlier qualifying
criteria are met. The estimated costs of the claim are
calculated by multiplying the total submitted charges, minus
the noncovered charges on the claim, by the hospital's ratio
of costs-to-charges (RCC) rate. The department identifies a
DRG high outlier claim based on the claim's estimated costs.
To qualify as a DRG high outlier claim, the department
determined estimated costs for the claim must be greater than
both the fixed outlier cost threshold of fifty thousand
dollars and one hundred seventy-five percent of the applicable
base DRG allowed amount for payment. These criteria are also
used to determine if a transfer claim qualifies for high
outlier payment when a transfer claim is submitted to the
department by a transferring hospital.__

__ For Children's Hospital Regional Medical Center, Mary
Bridge Children's Hospital and Health Center, and claims
grouped to neonatal and pediatric DRGs under the DRG payment
method, the department identifies a high outlier claim based
on the claim's estimated costs. To qualify as a high outlier
claim, the claim's estimated cost amount must be greater than
both the fixed outlier threshold of fifty thousand dollars and
one hundred fifty percent of the applicable base DRG allowed
amount for payment. __

__ (15) For dates of admission on and after August 1, 2007,
the department may allow an adjustment for a high outlier for
per diem claims grouped to a DRG classification in one of the
acute unstable DRG service categories, i.e., medical,
surgical, burn, and neonatal. These service categories are
described in subsection (16) of this section. __

__ The department identifies high outlier per diem claims
for medical, surgical, burn, and neonatal DRG service
categories based on the claim estimated costs. The claim
estimated costs are the total submitted charges, minus the
noncovered charges for the claim, multiplied by the hospital's
ratio of costs-to-charges (RCC) related to the admission. To
qualify as a high outlier claim, when a claim is grouped to
medical, surgical, burn, or neonatal DRG service category, the
claim's estimated cost amount must be greater than both the
fixed outlier threshold of fifty thousand dollars and one
hundred seventy-five percent of the applicable per diem base
allowed amount for payment.__

__ For Children's Hospital Regional Medical Center, Mary
Bridge Children's Hospital and Health Center, and claims
grouped to neonatal and pediatric DRGs under medical,
surgical, burn, and neonatal services categories, the
department identifies high outlier claims based on the claim's
estimated costs. To qualify as a high outlier claim, the
claim's estimated cost amount must be greater than both the
fixed outlier threshold of fifty thousand dollars and one
hundred fifty percent of the applicable per diem base allowed
amount for payment.__

__ The department performs retrospective prepay utilization
review on all per diem outlier claims that exceed the
department determined DRG average length of stay (LOS). If
the department determines the entire LOS or part of the LOS is
not medically necessary, the claim will be denied or the
payment will be adjusted.__

__ (16) For dates of admission on and after August 1, 2007,
the term "unstable" is used generically to describe an AP-DRG
classification that has fewer than ten occurrences (low
volume), or that is unstable based on the statistical
stability test indicated in this subsection, and to describe
such claims in the major service categories of per diem paid
claims identified in this section. The formula for the
statistical stability test calculates the required size of a
sample population of values necessary to estimate a mean cost
value with ninety percent confidence and within an acceptable
error of plus or minus twenty percent given the population's
estimated standard deviation.__

__ Specifically, this formula is:
__

__ N=(Z ^{2} * S^{2})/R^{2}, where__

__ • The Z statistic for 90 percent confidence is 1.64__

__ • S=the standard deviation for the AP-DRG classification,
and__

__ • R=acceptable error range, per sampling unit
__

__ If the actual number of claims within an AP-DRG
classification is less than the calculated N size for that
classification during relative weight recalibration, the
department designates that DRG classification as unstable for
purposes of calculating relative weights. And as previously
stated, for relative weight recalibration, the department also
designates any DRG classification having less than ten claims
in total in the claims sample used to recalibrate the relative
weights, as low volume and unstable.__

__ The DRG classification assigned to the per diem payment
method, that are in one of the following major services
categories in subsection (16)(a) through (d) of this section,
qualify for determination to ascertain if a high outlier
payment is appropriate. The department specifies those DRG
classifications to be paid the per diem payment method because
the DRG classification has low volume and/or unstable claims
data for determination of a AP-DRG relative weight. A claim
in a DRB classification that falls into one of the following
major services categories that the department designates for
per diem payment, may receive a per diem high outlier payment
when the claim meets the high outlier criteria as described in
subsection (15) of this section:__

__ (a) Neonatal claims, based on assignment to medical
diagnostic category (MDC) 15;__

__ (b) Burn claims based on assignment to MDC 22;__

__ (c) AP-DRG groups that include primarily medical
procedures, excluding any neonatal or burn per diem
classifications identified in (a) and (b) of this subsection;
and__

__ (d) AP-DRG groups that include primarily surgical
procedures, excluding any neonatal or burn per diem
classifications identified in (a) and (b) of this subsection.__

__ (17) For dates of admission on and after August 1, 2007,
the high outlier claim payment processes for the general
assistance-unemployable (GA-U) program are the same as those
for the medicaid or SCHIP DRG paid and per diem paid claims,
except that the DRG rates and per diem rates are reduced, and
the percent of outlier adjustment factor applied to the
payment may be reduced. The high outlier claim payment
process for medicaid or SCHIP DRG paid and per diem paid
claims is as follows:__

__ (a) The department determines the claim estimated cost
amount that is used in the determination of the high outlier
claim qualification and the high outlier threshold for the
calculation of outlier adjustment amount. The claim estimated
cost is equal to the total submitted charges, minus the
noncovered charges reported on the claim, multiplied by the
hospital's inpatient ratio of costs-to-charges (RCC) related
to the admission.__

__ (b) The high outlier threshold when calculating the high
outlier adjustment portion of the total payment allowed amount
on the claim is:__

__ (i) For DRG paid claims grouped to non-neonatal or
non-pediatric DRG classifications, and for DRG paid claims
that are not from Children's Hospital Regional Medical Center
or Mary Bridge Children's Hospital and Health Center, the high
outlier threshold is one hundred seventy-five percent of the
base DRG payment allowed amount;__

__ (ii) For DRG paid claims grouped to neonatal or pediatric
DRG classifications, and for DRG paid claims that are from
Children's Hospital Regional Medical Center or Mary Bridge
Children's Hospital and Health Center, the high outlier
threshold is one hundred fifty percent of the base DRG
payment allowed amount;__

__ (iii) For non-specialty service category per diem paid
claims grouped to non-neonatal and non-pediatric DRG
classifications, and for non-specialty service category per
diem paid claims that are not from Children's Hospital
Regional Medical Center or Mary Bridge Children's Hospital and
Health Center, the high outlier threshold is one hundred
seventy-five percent of the base per diem payment allowed
amount; and__

__ (iv) For non-specialty service category per diem paid
claims grouped to neonatal and pediatric DRG classifications,
and for all non-specialty service category per diem paid
claims from Children's Hospital Regional Medical Center and
Mary Bridge Children's Hospital and Health Center, the high
outlier threshold is one hundred fifty percent of the base
per diem payment allowed amount;__

__ (c) The high outlier payment allowed amount is equal to
the difference between the department's estimated cost of
services associated with the claim, and the high outlier
threshold for payment, the resulting amount being multiplied
by a percent of outlier adjustment factor. The percent of
outlier adjustment factor is:__

__ (i) Ninety-five percent for outlier claims that fall into
one of the neonatal or pediatric AP-DRG classifications. All
high outlier claims at Children's Hospital Regional Medical
Center and Mary Bridge Children's Hospital and Health Center
receive a ninety-five percent of outlier adjustment factor,
regardless of AP-DRG classification assignment;__

__ (ii) Ninety percent for outlier claims that fall into
burn-related AP-DRG classifications;__

__ (iii) Eighty-five percent for all other AP-DRG
classifications; and__

__ (iv) Reduced as indicated in WAC 388-550-4800 for
state-administered programs' claims that are eligible for a
high outlier payment.__

__ (d) The high outlier payment allowed amount is added to
the calculated allowed amount for the base DRG or base per
diem payment, respectively, to determine the total payment
allowed amount for the claim.__

__DRG high outlier____Three examples for medicaid or SCHIP DRG high outlier claim qualification and payment calculation (admission
dates are on or after August 1, 2007). Example dollar amounts are approximated and not based on real claims data.____Total
Submitted
Charges
minus
Noncovered
Charges____Base DRG
Payment
Allowed
Amount ^{1}__

__ All examples represent a claim that is a non-psychiatric
claim and a claim that isn't from Children's Hospital Regional
Medical Center or Mary Bridge Children's Hospital and Health
Center.__

__ Example one: The claim meets high cost outlier criteria.
Example dollar amounts are approximated and not based on real
claims data:__

__ ^{1}DRG conversion factor times DRG relative weight= Base DRG
allowed amount__

__ $6,300 x 4.5773 = $28,837 = Base DRG allowed amount__

__ ^{2}Total submitted charges minus total noncovered charges
times RCC rate = Department determined estimated costs__

__ $95,600 x 65% = $62,140 = Department determined estimated
costs__

__ ^{3}If department determined estimated costs are greater than
the outlier qualifying criteria (in this example $50,000),
then (department determined estimated costs minus 175% of base
DRG payment allowed amount (high outlier payment threshold))
times claim's percent of outlier adjustment factor (see
subsection (17)(c)(i), (ii) and (iii)) = High outlier portion
allowed amount, if greater than $0, otherwise $0. __

__ $62,140 - $50,465 = $11,675 x 85% = $9,924 = High outlier
portion allowed amount__

__ ^{4}Base DRG payment allowed amount plus high outlier portion
allowed amount = Total DRG high outlier claim payment amount__

__ $28,837 + $9,924 = $38,761__

__ Example two: The claim does not meet high cost outlier
criteria due to department-determined estimated cost being
less than $50,000. Example dollar amounts are approximated
and not based on real claims data:__

__ ^{1}DRG conversion factor times DRG relative weight= Base DRG
allowed amount__

__ $6,300 x 4.5773 = $28,837 = Base DRG allowed amount__

__ ^{2}Total submitted charges minus total noncovered charges
times RCC rate = Department determined estimated costs__

__ $64,500 x 65% = $41,925 = Department determined estimated
costs__

__ ^{3}If department determined estimated costs are greater than
the outlier qualifying criteria, then (department determined
estimated costs minus 175% of base DRG payment allowed amount
(high outlier payment threshold)) times claim's percent of
outlier adjustment factor (see subsection (17)(c)(i), (ii) and
(iii))= High outlier portion allowed amount, if greater than
$0, otherwise $0.__

__ ($41,925 - $50,465 = ($8,540)) x 85% = ($7,259), which is
converted to $0. Also, $41,925 is not greater than $50,000, so
the claim does not meet the high outlier qualifying criteria.
Therefore, the high outlier portion allowed amount is $0.__

__ ^{4}Base DRG payment allowed amount plus high outlier portion
allowed amount = Total DRG high outlier claim payment allowed
amount__

__ $28,837 + $0 = $28,837__

__ Example three: The claim does not meet high outlier
criteria due to high DRG allowed amount. Example dollar
amounts are approximated and not based on real claims data:__

__ ^{1}DRG conversion factor times DRG relative weight = Base
DRG allowed amount__

__ $6,300 x 4.5773 = $28,837 = Base DRG allowed amount__

__ ^{2}Total submitted charges minus total noncovered charges
times RCC rate = Department determined estimated costs__

__ $77,000 x 65% = $50,050 = Department determined estimated
costs__

__ ^{3}If department determined estimated costs are greater than
the outlier qualifying criteria, then (department determined
estimated costs minus 175% of base DRG payment allowed amount
(high outlier payment threshold)) times claim's percent of
outlier adjustment factor (see subsection (17)(c)(i), (ii) and
(iii))= high outlier portion allowed amount, if greater than
$0, otherwise $0.__

__ ($50,050 - $50,465 = ($415)) x 85% = ($353), which is
converted to $0. Also, $50,050 is greater than $50,000, but
not greater than $50,465, so the claim does not meet the high
outlier qualifying criteria. Therefore, the high outlier
portion allowed amount is $0.__

__ ^{4}Base DRG payment allowed amount plus high outlier portion
allowed amount = Total DRG high outlier claim payment allowed
amount__

__ $28,837 + $0 = $28,837__

__Per Diem High Outlier____Three examples for medicaid and SCHIP per diem high outlier claim qualification and payment calculation
(admission dates are on or after August 1, 2007). Example dollar amounts are approximated and not based on real
claims data.____Total
Submitted
Charges Less
Total
Noncovered
Charges____Base Per
Diem
Payment
Allowed
Amount ^{1}__

__ All examples represent a claim that is a non-psychiatric
claim and a claim that isn't from Children's Hospital Regional
Medical Center or Mary Bridge Children's Hospital and Health
Center.__

__ Example one: The claim meets high cost outlier criteria.
Example dollar amounts are approximated and not based on real
claims data:__

__ ^{1}Per diem rate times client's department recognized length
of stay for eligible days = Base per diem allowed amount__

__ $1,000 (rate) x 25 (days) = $25,000 = Base per diem
allowed amount__

^{2}Total submitted charges minus total noncovered charges
times RCC rate = Department determined estimated costs

__ $100,000 x 70% = $70,000 = Department determined
estimated costs__

__ ^{3}If department determined estimated costs are greater than
the outlier qualifying criteria, then (department determined
estimated costs minus 175% of base per diem payment allowed
amount (high outlier payment threshold)) times claim's percent
of outlier adjustment factor (see subsection (17)(c)(i), (ii)
and (iii)) = High outlier portion allowed amount, if greater
than $0, otherwise $0.__

__ ($70,000 - $43,750 = $26,250) x 85% = $22,313 = High
outlier portion allowed amount__

__ ^{4}Base per diem payment allowed amount plus high outlier
portion allowed amount = Total per diem high outlier claim
payment allowed amount__

__ $25,000 + $22,313 = $47,313__

__ Example two: The claim does not meet high cost outlier
criteria due to department-determined estimated cost being
less than $50,000. Example dollar amounts are approximated
and not based on real claims data:__

__ ^{1}Per diem rate times client's department recognized length
of stay for eligible days = Base per diem allowed amount__

__ $1,000 x 25 = $25,000 = Base per diem allowed amount__

^{2}Total submitted charges minus total noncovered charges
times RCC rate = Department determined estimated costs

__ $64,500 x 70% = $45,150 = Department determined estimated
costs__

__ ^{3}If department determined estimated costs are greater than
the outlier qualifying criteria, then (department determined
estimated costs minus 175% of base per diem payment allowed
amount (high outlier payment threshold)) times claim's percent
of outlier adjustment factor (see subsection (17)(c)(i), (ii)
and (iii))= High outlier portion allowed amount, if greater
than $0, otherwise $0.__

__ ($45,150 - $43,750 = $1,400), but $45,150 is not greater
than $50,000, so the claim does not meet the high outlier
qualifying criteria. Therefore, the high outlier portion
allowed amount is $0.__

__ ^{4}Base per diem payment allowed amount plus high outlier
portion allowed amount = Total per diem high outlier claim
payment allowed amount__

__ $25,000 + $0 = $25,000__

__ Example three: (The claim does not meet high outlier
criteria due to high DRG allowed amount. Example dollar
amounts are approximated and not based on real claims data):__

__ ^{1}Per diem rate times client's department recognized length
of stay for eligible days = Base per diem allowed amount__

__ $1,000 x 35 = $35,000 = Base per diem allowed amount__

^{2}Total submitted charges minus total noncovered charges
times RCC rate = Department determined estimated costs

__ $75,000 x 70% = $52,500 = Department determined estimated
costs__

__ ^{3}If department determined estimated costs are greater than
the outlier qualifying criteria, then (department determined
estimated costs minus 175% of base DRG payment allowed amount
(high outlier payment threshold)) times claim's percent of
outlier adjustment factor (see subsection (17)(c)(i), (ii) and
(iii)) = High outlier portion allowed amount, if greater tan
$0, otherwise $0.__

__ ($52,500 - $61,250 = (8,750)) x 85% = ($7,438), which is
converted to $0. Also, $52,500 is greater than $50,000, but
not greater than $61,250, so the claim does not meet the high
outlier qualifying criteria. Therefore, the high outlier
portion allowed amount is $0.__

__ ^{4}Base per diem payment allowed amount plus high outlier
portion allowed amount = Total per diem high outlier claim
payment allowed amount__

__ $35,000 + $0 = $35,000__

__ (18) The department makes all applicable claim payment
adjustments for client responsibility, third party liability,
medicare, etc., to the payment.__

[Statutory Authority: RCW 74.08.090, 74.09.500. 03-13-053, § 388-550-3700, filed 6/12/03, effective 7/13/03. Statutory Authority: RCW 74.08.090 and 42 U.S.C. 1395x(v), 42 C.F.R. 447.271, .11303, and .2652. 01-16-142, § 388-550-3700, filed 7/31/01, effective 8/31/01. Statutory Authority: RCW 74.08.090, 42 USC 1395 x(v), 42 CFR 447.271, 447.11303 and 447.2652. 99-06-046, § 388-550-3700, filed 2/26/99, effective 3/29/99. Statutory Authority: RCW 74.08.090, 74.09.730, 74.04.050, 70.01.010, 74.09.200, [74.09.]500, [74.09.]530 and 43.20B.020. 98-01-124, § 388-550-3700, filed 12/18/97, effective 1/18/98.]