Emergency-Based and Post-Stabilization Services

Claims for all emergency and approved post-stabilization acute inpatient services at all nonparticipating hospitals, including public and out-of-state hospitals, are paid using the diagnosis-related group (DRG) pricing payment methodology in accordance with 42 CFR 438.114 and APL 19-008. The All Patient Refined DRGs (APR-DRGs) pricing methodology is used to assign DRGs to claims.

To the extent acute rehabilitation services are provided at nonparticipating hospitals on an emergency or post-stabilization basis, Medi-Cal managed care plans may not pay more than the statewide per diem rate that DHCS is developing.

Health Net pays claims for participating hospitals based on Provider Participation Agreement (PPA).

Refer to www.dhcs.ca.gov/provgovpart/Pages/DRG.aspx for additional information on DRG.

Health Net's Prestabilization Services Policy

The following defines Health Net's policy on prestabilization services:

1. The first day of all emergency admissions is prestabilization.
2. When a claim is billed with specific revenue codes or bed type and the emergency room stay is greater than one day, the days for which these bed types and services are used are considered prestabilization:
   • Intensive care unit (ICU), coronary care unit (CCU), pediatric ICU, and neonatal ICU (NICU) levels III and IV
   • Certain obstetrics services up to and including the day of delivery

Health Net's Post-Stabilization Services Policy

Any services not defined under the prestabilization services policy section above and claims submitted with subsequent hospital days thereafter are paid according to the most recent APL 13-004, Rates for Emergency and Post-Stabilization Acute Inpatient Services Provided by Out-Of-Network General Acute Care Hospitals Based on Diagnosis Related Groups.