PDFWAC 182-550-7600
OPPS payment calculation.
(1) The medicaid agency calculates the enhanced ambulatory patient group (EAPG) payment as follows:
EAPG payment =
EAPG relative weight x
Hospital-specific conversion factor x
Discount factor (if applicable) x
Policy adjustor (if applicable)
(2) The total OPPS claim payment is the sum of the EAPG payments plus the sum of the allowed amounts for each nonEAPG service.
(3) If a client's third-party liability insurance has made a payment on a service, the agency subtracts any such payments made from the medicaid allowed amount.
[Statutory Authority: RCW 41.05.021 and chapter 74.60 RCW. WSR 14-14-049, § 182-550-7600, filed 6/25/14, effective 7/26/14. WSR 11-14-075, recodified as § 182-550-7600, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.04.050, 74.04.057, 74.08.090, 74.09.500, and 2009-11 Omnibus Operating Budget (ESHB 1244). WSR 09-12-062, § 388-550-7600, filed 5/28/09, effective 7/1/09. Statutory Authority: RCW 74.08.090, 74.09.500. WSR 07-13-100, § 388-550-7600, filed 6/20/07, effective 8/1/07; WSR 04-20-061, § 388-550-7600, filed 10/1/04, effective 11/1/04.]