NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
ABBOTT NORTHWESTERN HSP MN
ACADIA HOSPITAL ME
ACUTE CARE SPECIALTY OH
ADVENTIST MED CTR OR
AKRON GENERAL MEDICAL CENTER
ALAMANCE REG MED CTR NC
ALBERT EINSTEIN MED CTR PA
ALEGENT HLTH IMMANUEL MED NE
ALEXIAN BROTHERS MEDICAL CENT
ALFRED I DUPONT HOSP FOR CHID
ALL CHILDRENS HOSPITAL FL
ALLEGHENY GENERAL HOSPITAL PA
ALLEGHENY GENERAL HOSPITAL PA
ALLEGIANCE HEALTH MI
ALLE‐KISKI MEDICAL CENTER PA
ALTON MEM HSP
ALTRU HOSPITAL ND
ANDROSOGGIN VALLEY HOPS NH
ANTELOPE VALLEY HSP CA
ARIA HEALTH‐FRANKFORD CAMPUS
ARKANSAS CHILDRENS HOSP AR
AROOSTOOK MEDICAL CENTER ME
ARROWHEAD REG HSP CA
ASPEN VALLEY HOSPITAL CO
ATHENS LIMESTONE HSP AL
ATHENS REG MED TN
ATLANTA MEDICAL CENTER GA
ATLANTIC GEN HSP MD
ATLANTICARE REG MED CTR CITY ATMORE COMM HSP AL
AUGUSTA MEDICAL CENTER VA
AVENTURA HOSP & MED CTR FL
AVERA MCKENNAN HOSP&UNIV HLTH
BALTIMORE WASHINGTON MEDICAL BANNER BAYWOOD MED CTR AZ
BANNER BEHAVIORAL HLTH AZ
BANNER DEL E WEBB MEM HSP AZ
BANNER DESERT MED CTR AZ
BANNER ESTRELLA MED CTR AZ
BANNER GATEWAY MC AZ
BANNER GOOD SAMARITAN MED AZ
BANNER HEART HOSPITAL AZ
BANNER IRONWOOD MED CTR AZ
BANNER THUNDERBIRD MED CTR AZ
BAPTIST HOSPITAL FL
BAPTIST HOSPITAL OF MIAMI FL
BAPTIST MEM HOSP DESOTO MS
BAPTIST MEM HOSP NORTH MS
BAPTIST MEM HOSP OF MEMPHIS
City, State
MINNEAPOLIS
BANGOR
CANTON
PORTLAND
AKRON
BURLINGTON
PHILADELPHIA
OMAHA
ELK GROVE VILLAGE
WILMINGTON
ST PETERSBURG
PITTSBURGH
PITTSBURGH
JACKSON
NATRONA HEIGHTS
GLENDALE
GRAND FORKS
BERLIN
LANCASTER
PHILADELPHIA
LITTLE ROCK
PRESQUE ISLE
COLTON
ASPEN
ATHENS
ATHENS
ATLANTA
BERLIN
ATLANTIC CITY
ATMORE
FISHERSVILLE
AVENTURA
SIOUX FALLS
GLEN BURNIE
MESA
SCOTTSDALE
SUN CITY
MESA
PHOENIX
GILBERT
PHOENIX
MESA
SAN TAN VALLEY
GLENDALE
PENSACOLA
MIAMI
SOUTHAVEN
OXFORD
MEMPHIS
MN
ME
OH
OR
OH
NC
PA
NE
IL
DE
FL
PA
PA
MI
PA
AZ
ND
NH
CA
PA
AR
ME
CA
CO
AL
TN
GA
MD
NJ
AL
VA
FL
SD
MD
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
AZ
FL
FL
MS
MS
TN
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
1 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
BAPTIST ST ANTHONYS MEM HOSP BARBERTON CITIZENS HOSP OH
BARNES JEWISH HSP MO
BARNES‐KASSON COUNTY HSP
BARTON MEMORIAL HOSPITAL CA
BAY MEDICAL CTR FL
BAYHEALTH KENT GEN HSP DE
BAYLOR ALL SAINTS MED CTR TX
BAYLOR MED CTR GARLAND TX
BAYLOR MED CTR GRAPE VINE TX
BAYLOR UNIVERSITY MED CTR TX
BAYONNE MEDICAL CENTER NJ
BAYSHORE COMMUNITY HOSPITAL
BAYSTATE MEDICAL CENTER MA
BEAUFORT MEMORIAL HSP SC
BEEBE MEDICAL CENTER DE
BERGEN PINES COUNTY HSP NJ
BERKSHIRE HEALTH SYSTEM MA
BERKSHIRE MEDICAL CTR MA INC
BERT FISH MEDICAL CENTER FL
BERTIE MEMORIAL HSP NC
BETH ISRAEL DEACONESS BOSTON BETHESDA MEMORIAL HOSPITAL FL
BETSY JOHNSON REG HOSP NC
BLAKE MEDICAL CENTER FL
BLOOMINGTON HSP IN
BLOOMSBURG HOSPITAL PA
BLUE RIDGE HOSP NC
BLUEFIELD HOSPITAL CO WV
BOCA RATON COMM HOSP FL
BOLIVAR MED CTR/PHC CLEVELAND
BON SECOURS DEPAUL MED CTR VA
BON SECOURS MEM REG VA
BON SECOURS RICHMOND COMM VA
BORGESS MEDICAL CENTER MI
BOSTON MEDICAL CENTER MA
BOTSFORD HOSPITAL MI
BOZEMAN DEACONESS HOSP MT
BRACKENRIDGE HSP TX
BRADFORD REGIONAL MED CTR PA
BRANDON HOSPITAL FL
BRATTLEBORO MEM HOSPITAL VT
BRATTLEBORO RETREAT HSP VT
BRIDGEPORT HOSPITAL
BRIGHAM AND WOMENS HOSP
BRISTOL HOSPITAL
BROCKTON HOSP MA
BROMENN REG MED CTR IL
BRONSON METHODIST HOSP MI
City, State
AMARILLO
BARBERTON
SAINT LOUIS
SUSQUEHANNA
SOUTH LAKE TAHOE
PANAMA CITY
DOVER
FORT WORTH
GARLAND
GRAPEVINE
DALLAS
BAYONNE
HOLMDEL
SPRINGFIELD
BEAUFORT
LEWES
PARAMUS
PITTSFIELD
PITTSFIELD
NEW SMYRNA BEACH
WINDSOR
BOSTON
BOYNTON BEACH
DUNN
BRADENTON
BLOOMINGTON
BLOOMSBURG
SPRUCE PINE
BLUEFIELD
BOCA RATON
CLEVELAND
NORFOLK
MECHANICSVILLE
RICHMOND
KALAMAZOO
BOSTON
FARMINGTON HILLS
BOZEMAN
AUSTIN
BRADFORD
BRANDON
BRATTLEBORO
BRATTLEBORO
BRIDGEPORT
BOSTON
BRISTOL
BROCKTON
NORMAL
KALAMAZOO
TX
OH
MO
PA
CA
FL
DE
TX
TX
TX
TX
NJ
NJ
MA
SC
DE
NJ
MA
MA
FL
NC
MA
FL
NC
FL
IN
PA
NC
WV
FL
MS
VA
VA
VA
MI
MA
MI
MT
TX
PA
FL
VT
VT
CT
MA
CT
MA
IL
MI
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 7,101.21
$ 7,101.21
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 8,549.14
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 8,549.14
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 1,295.15
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 1,295.15
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
2 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
BROOKEGLEN BEHAVIORAL HOSPITA
BROOKWOOD MED CTR AL
BROWARD GENERAL MEDICAL CTR
BRUNSWICK COMM HOSP NC
BRYANLGH MED CTR EAST NE
BRYN MAWR HOSPITAL PA
BRYN MAWR REHAB HOSP. PA
CAMDEN CLARK MEMORIAL HOSP WV
CANDLER HOSP GA
CAPE CANAVERAL HOSP FL
CAPE CORAL HSP FL
CAPE FEAR VALLEY NC
CAPE REGIONAL MEDICAL CENTER CAPITAL HEALTH SYS AT FULD
CAPITAL HEALTH SYSTEM MERCER
CARILION FRANKLIN MEMORIAL VA
CARILION ROANOKE COMM HSP VA
CARILION ROANOKE MEMORIAL
CARILION STONEWALL JACKSN VA
CARITAS CARNE HSP MA
CARITAS NORWOOD HOSP MA
CARLE FOUNDATION HOSP IL
CAROLINAEAST HEALTH SYSTEM
CAROLINAS MEDICAL CENTER NORT
CAROLINAS MEDICAL CTR UNION N
CARONDELET HOLY CROSS HSP AZ
CARONDELET ST JOSEPHS HSP AZ
CARONDELET ST MARYS HOSP AZ
CARROLL HOSPITAL CENTER MD
CASA GRANDE REG MED CTR AZ
CASS COUNTY MEMORIAL HSP IA
CASTLE MEDICAL CENTER HI
CATAWBA VALLEY MED CTR NC
CATHOLIC HTHCRE WEST(ST ROSE)
CATHOLIC MED CTR NH
CENTENNIAL HILLS HOSP MED CTR
CENTENNIAL MED CTR TN
CENTENNIAL MEDICAL CENTER TX
CENTRA VIRGINIA BAPTST HSP VA
CENTRAL BAPTIST HOSPITAL KY
CENTRAL CAROLINA HOSPITAL NC
CENTRAL MONTGOMERY MC PA
CENTRAL PENINSULA GEN AK
CENTRAL VERMONT HOSPITAL
CENTRASTATE MED CTR NJ
CENTURA PENROSE ST FRANCIS HL
CHAMBERSBURG HOSPITAL PA
CHARLES COLE MEMORIAL HSP
CHARLESTON AREA MED CTR WV
City, State
FORT WASHINGTON
BIRMINGHAM
FT LAUDERDALE
BOLIVIA
LINCOLN
BRYN MAWR
MALVERN
PARKERSBURG
SAVANNAH
COCOA BEACH
CAPE CORAL
FAYETTEVILLE
CAPE MAY COURT HOUSE
TRENTON
TRENTON
ROCKY MOUNT
ROANOKE
ROANOKE
LEXINGTON
DORCHESTER CENTER
NORWOOD
URBANA
NEW BERN
CONCORD
MONROE
NOGALES
TUCSON
TUCSON
WESTMINSTER
CASA GRANDE
ATLANTIC
KAILUA
HICKORY
LAS VEGAS
MANCHESTER
LAS VEGAS
NASHVILLE
FRISCO
LYNCHBURG
LEXINGTON
SANFORD
LANSDALE
SOLDOTNA
BARRE
FREEHOLD
COLORADO SPRINGS
CHAMBERSBURG
COUDERSPORT
CHARLESTON
PA
AL
FL
NC
NE
PA
PA
WV
GA
FL
FL
NC
NJ
NJ
NJ
VA
VA
VA
VA
MA
MA
IL
NC
NC
NC
AZ
AZ
AZ
MD
AZ
IA
HI
NC
NV
NH
NV
TN
TX
VA
KY
NC
PA
AK
VT
NJ
CO
PA
PA
WV
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 8,549.14
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 1,295.15
$ 298.23
$ 298.23
$ ‐
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
3 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
CHARLOTTE HUNGERFORD HOSPITAL
CHARLOTTE REGIONAL MC FL
CHESAPEAKE GENERAL HOSP VA
CHESHIRE MEDICAL CTR NH
CHESTER COUNTY HOSP PA
CHHS HOSP CO/CHESTNUT HILL
CHILDRENS HOME OF PITTSBURGH CHILDRENS HOSP LA
CHILDRENS HOSP & RESEARCH CA
CHILDRENS HOSP M C OH
CHILDRENS HOSP MED CTR OH
CHILDRENS HOSP OF MI
CHILDRENS HOSP OF PHILA PA
CHILDRENS HOSP OF WI
CHILDRENS HOSPITAL ALABAMA
CHILDRENS HOSPITAL CO
CHILDRENS HOSPITAL MA
CHILDRENS HOSPITAL OF PITTS
CHILDRENS HOSPITAL OF PITTS
CHILDRENS HOSPITAL OH
CHILDRENS HSP KINGS DAUGHTER
CHILDRENS HSP REG MED CTR WA
CHILDRENS INSTITUTE OF PITTS
CHILDRENS MEDICAL CENTER OH
CHILDRENS MEM HSP IL
CHILDRENS MERCY HOSPITAL MO
CHILDRENS NATIONAL MED CTR
CHILDRENS SPECIALIZED HOSP NJ
CHILTON MEM HOSP NJ
CHIPPENHAM JOHNSTON WILLIS VA
CHOWAN HOSPITAL NC INC
CHRIST HOSPITAL NJ
CHRIST HSP & MED CTR IL
CHRISTIAN HOSP NORTHEAST MO
CHRISTIANA CARE HLTH SERV DE
CHRISTUS HLTH NORTHERN LOUISI
CITRUS MEMORIAL HOSPITAL FL
CITY HOSPITAL WV
CLARA MAASS MEM HOSP
CLARION HOSPITAL PA
CLARION PSYCHIATRIC CTR PA
CLEARFIELD HOSPITAL PA
CLEVELAND CLINIC FOUNDATION
CLEVELAND CLINIC HOSPITAL FL
COLUMBIA DOCTORS HSP FL
COLUMBIA HENRICO DOCTORS VA
COLUMBIA WESLEY MEDICAL CENTE
COMMUNITY HLTH CTR BRANCH CTY
COMMUNITY HOSPITAL ASSOCIATIO
City, State
TORRINGTON
PUNTA GORDA
CHESAPEAKE
KEENE
WEST CHESTER
PHILADELPHIA
PITTSBURGH
NEW ORLEANS
OAKLAND
CINCINNATI
AKRON
DETROIT
PHILADELPHIA
MILWAUKEE
BIRMINGHAM
AURORA
BOSTON
PITTSBURGH
PITTSBURGH
COLUMBUS
NORFOLK
SEATTLE
PITTSBURGH
DAYTON
CHICAGO
KANSAS CITY
WASHINGTON
MOUNTAINSIDE
POMPTON PLAINS
RICHMOND
EDENTON
JERSEY CITY
OAK LAWN
ST LOUIS
WILMINGTON
SHREVEPORT
INVERNESS
MARTINSBURG
TOMS RIVER
CLARION
CLARION
CLEARFIELD
CLEVELAND
WESTON
SARASOTA
RICHMOND
WICHITA
COLDWATER
BOULDER
CT
FL
VA
NH
PA
PA
PA
LA
CA
OH
OH
MI
PA
WI
AL
CO
MA
PA
PA
OH
VA
WA
PA
OH
IL
MO
DC
NJ
NJ
VA
NC
NJ
IL
MO
DE
LA
FL
WV
NJ
PA
PA
PA
OH
FL
FL
VA
KS
MI
CO
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 7,101.21
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ ‐
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 8,549.14
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 1,611.88
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 1,295.15
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ ‐
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
4 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ ‐
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
COMMUNITY HOSPITALS IN
COMMUNITY HSP OF OTTAWA IL
COMMUNITY MEDICAL CENTER PA
COMMUNITY MEMORIAL HOSP VA
CONCORD HOSPITAL NH
CONEMAUGH VALLEY MEM HSP PA
CONNECTICUT CHILDRENS MED CTR
CONWAY HOSPITAL SC
COOKEVILLE REG MED CTR TN
COOLEY DICKINSON HOSP MA
COOPER MED CTR CAMDEN NJ
COPLEY HOSPITAL VT INC
CORAL GABLES HOSPITAL FL
CORAL SPRINGS MEDICAL CTR FL
CORRY MEMORIAL HOSPITAL PA
COSHOCTON CO MEM HOSPITAL OH
COTTAGE HOSPITAL NH
COVENANT HEALTHCARE MI
COVENANT MEDICAL CENTER IA
CREIGHTON UNIV MED CTR NE
CRESTWOOD MEDICAL CENTER AL
CROZER‐CHESTER MEDICAL CTR PA
CULPEPER MEM HOSP VA
CUMBERLAND HOSP VA
CUSHING MEMORIAL HOSPITAL KS
DANA FARBER CANCER INSTITUTE
DANBURY HOSP CT
DANVILLE REG MED CTR VA
DAVIS HOSPITAL AND MED CTR UT
DAVIS MEMORIAL HOSPITAL WV
DAY KIMBALL HOSPITAL CT
DEACONESS HOSPITAL IN
DEACONESS HOSPITAL OK
DEACONESS HOSPITAL WA
DEBORAH HEART AND LUNG CTR
DECATUR GEN HOSPITAL AL
DEL SOL MEDICAL CENTER TX
DELAWARE CTY MEMORIAL HSP PA
DELRAY MEDICAL CTR FL
DELTA CTY MEM HSP CO
DESERT SPRINGS HOSP NV
DETROIT RECEIVING HSP MI
DETROIT RECEIVING HSP MI
DIXIE MEDICAL CENTER UT
DOCTORS COMMUNITY HOSPITAL MD
DOCTORS HOSP OF AUGUSTA GA
DOCTORS HOSPITAL TX
DOYLESTOWN HOSPITAL PA
DUBOIS REG MED CTR MERCY DIV
City, State
INDIANAPOLIS
OTTAWA
SCRANTON
SOUTH HILL
CONCORD
JOHNSTOWN
HARTFORD
CONWAY
COOKEVILLE
NORTHAMPTON
CAMDEN
MORRISVILLE
CORAL GABLES
CORAL SPRINGS
CORRY
COSHOCTON
WOODSVILLE
SAGINAW
WATERLOO
OMAHA
HUNTSVILLE
UPLAND
CULPEPER
NEW KENT
LEAVENWORTH
BOSTON
DANBURY
DANVILLE
LAYTON
ELKINS
PUTNAM
EVANSVILLE
OKLAHOMA CITY
SPOKANE
BROWNS MILLS
DECATUR
EL PASO
DREXEL HILL
DELRAY BEACH
DELTA
LAS VEGAS
DETROIT
DETROIT
ST GEORGE
LANHAM
AUGUSTA
DALLAS
DOYLESTOWN
DUBOIS
IN
IL
PA
VA
NH
PA
CT
SC
TN
MA
NJ
VT
FL
FL
PA
OH
NH
MI
IA
NE
AL
PA
VA
VA
KS
MA
CT
VA
UT
WV
CT
IN
OK
WA
NJ
AL
TX
PA
FL
CO
NV
MI
MI
UT
MD
GA
TX
PA
PA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 8,549.14
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 1,295.15
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
5 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
DUKE RALEIGH HOSPITAL NC
DUKE UNIVERSITY HOSPITAL NC
DURHAM REGIONAL HOSPITAL NC
DYERSBURG HOSPITAL CORP TN
EAST COOPER MEDICAL CTR SC
EAST JEFFERSON GEN HOSP LA
EAST ORANGE GENERAL HOSPITAL
EAST TENNESSE CHILD HOSP
EASTERN IDAHO REG MED CTR ID
EASTERN MAINE MED CTR ME
EASTON HOSPITAL PA
EDWARD W SPARROW HSP MI
EDWARD WHITE HOSPITAL FL
EHS TRINITY HOSP IL
ELIZA COFFEE MEMORIAL HOSP AL
ELLIOT HOSPITAL NH
ELMORE MEDICAL CTR ID
EMMA PENDLETON BRADLEY HSP RI
EMORY ADVENTIST HOSP GA
EMORY UNIV HSP MIDTOWN GA
EMORY UNIVERSITY HSP GA
ENGLEWOOD COMM HOSP FL
ENGLEWOOD HOSP MED CTR NJ
ERLANGER MED CTR TN
EXEMPLA ST JOSEPH HOSPITAL FAIRBANKS MEM HSP AK
FAIRFAX HOSPITAL VA
FAIRVIEW GENERAL HOSPITAL OH
FAIRVIEW HOSPITAL
FAIRVIEW SOUTHDALE HSP MN
FAIRVIEW UNIV MED CTR MN
FALMOUTH HOSP ASSOC MA
FAYETTE COUNTY HOSPITAL
FEATHER RIVER HOSPITAL CA
FIRELANDS REG MED CTR OH
FIRST HEALTH OF CAROLINAS NC
FLAGLER HOSPITAL FL
FLAGSTAFF HOSP AND MED CTR AZ
FLETCHER ALLEN HLTH ‐ MCHV
FLORIDA HOSP HEARTLAND FL
FLORIDA HOSP MED CTR FL
FLORIDA HOSP WATERMAN FL
FLORIDA HOSPITAL DELAND FL
FLORIDA HOSPITAL ZEPHYR HILLS
FLORIDA HSP FISH MEMORIAL FL
FLOWER MEM HSP OH
FLOWERS HOSPITAL AL
FOUNDATIONS BEHAVIORAL HEALTH
FRANCISCAN HOSPITAL FOR CHILD
City, State
RALEIGH
DURHAM
DURHAM
DYERSBURG
MT PLEASANT
METAIRE
EAST ORANGE
KNOXVILLE
IDAHO FALLS
BANGOR
EASTON
LANSING
ST PETERSBURG
CHICAGO
FLORENCE
MANCHESTER
MOUNTAIN HOME
RIVERSIDE
SMYRNA
ATLANTA
ATLANTA
ENGLEWOOD
ENGLEWOOD
CHATTANOOGA
DENVER
FAIRBANKS
FALLS CHURCH
CLEVELAND
GT BARRINGTON
EDINA
MINNEAPOLIS
FALMOUTH
VANDALIA
PARADISE
SANDUSKY
PINEHURST
ST AUGUSTINE
FLAGSTAFF
BURLINGTON
SEBRING
ORLANDO
TAVARES
DELAND
ZEPHYRHILLS
ORANGE CITY
SYLVANIA
DOTHAN
DOYLESTOWN
BRIGHTON
NC
NC
NC
TN
SC
LA
NJ
TN
ID
ME
PA
MI
FL
IL
AL
NH
ID
RI
GA
GA
GA
FL
NJ
TN
CO
AK
VA
OH
MA
MN
MN
MA
IL
CA
OH
NC
FL
AZ
VT
FL
FL
FL
FL
FL
FL
OH
AL
PA
MA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 7,101.21
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 8,549.14
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 7,015.09
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 1,295.15
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 726.75
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
6 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
FRANKLIN REGIONAL MEDICAL CTR
FRANKLIN SQUARE HOSP MD
FROEDTERT MEM LUTHER WI
FRYE REGIONAL MED CTR NC
GARDEN CITY OSTEO HOSP MI
GARDEN GROVE HOSP MC CA
GASTON MEMORIAL HOSPITAL NC
GATEWAY MED CTR TN
GEARY COMMUNITY HSP KS
GEISINGER MEDICAL CENTER PA
GEISINGER SOUTH WILKES‐BARRE GEISINGER WYOMING VALLEY MED
GEORGETOWN MEMORIAL HOSP SC
GEORGETOWN UNIVERSITY HOSP DC
GERALD CHAMPION MEM HSP NM
GETTYSBURG HOSPITAL
GNADEN HUETTEN MEM HOSP PA
GOOD SAMARITAN HOSPITAL IN
GOOD SAMARITAN HOSPITAL MD
GOOD SAMARITAN HOSPITAL OH
GOOD SAMARITAN HSP FL
GOOD SAMARITAN HSP IL
GOOD SHEPHERD REHAB HOSP PA
GRACE COTTAGE HOSPITAL VT
GRADY MEMORIAL HOSPITAL
GRAND STRAND REG MED CTR SC
GRAND VIEW HOSP PA
GRANITE CITY ILLINOIS HOSP
GRANT MEDICAL CENTER OH
GREATER BALTIMORE MED CTR MD
GREENVIEW HOSPITAL KY
GREENVILLE MEM HSP SC
GREENWICH HOSP ASSOCIATION CT
GREER MEMORIAL HOSP SC
GRIFFIN HOSPITAL CT
GROSSMONT HOSPITAL CA
GUNDERSEN LUTHERAN MED CTR WI
HACKENSACK UNIV MED CTR NJ
HACKETTSTOWN REG MED CTR
HACKLEY HOSPITAL MI
HALIFAX MED CTR FL
HALIFAX REGIONAL HOSP VA
HAMOT MEDICAL CENTER PA
HAMPSHIRE MEMORIAL HOSP WV
HANOVER HOSPITAL PA
HARBORVIEW MED CTR WA
HARDIN MEMORIAL HOSPITAL KY
HARFORD MEMORIAL HOSP MD
HARPER HUTZEL HOSPITAL MI
City, State
LOUISBURG
BALTIMORE
MILWAUKEE
HICKORY
GARDEN CITY
GARDEN GROVE
GASTONIA
CLARKSVILLE
JUNCTION CITY
DANVILLE
WILKES BARRE
WILKES BARRE
GEORGETOWN
WASHINGTON
ALAMOGORDO
GETTYSBURG
LEHIGHTON
VINCENNES
BALTIMORE
DAYTON
WEST PALM BEACH
DOWNERS GROVE
ALLENTOWN
TOWNSHEND
ATLANTA
MYRTLE BEACH
SELLERSVILLE
GRANITE CITY
COLUMBUS
BALTIMORE
BOWLING GREEN
GREENVILLE
GREENWICH
GREER
DERBY
LA MESA
LA CROSSE
HACKENSACK
HACKETTSTOWN
MUSKEGON
DAYTONA BEACH
SOUTH BOSTON
ERIE
ROMNEY
HANOVER
SEATTLE
ELIZABETHTOWN
HAVRE DE GRACE
DETROIT
NC
MD
WI
NC
MI
CA
NC
TN
KS
PA
PA
PA
SC
DC
NM
PA
PA
IN
MD
OH
FL
IL
PA
VT
GA
SC
PA
IL
OH
MD
KY
SC
CT
SC
CT
CA
WI
NJ
NJ
MI
FL
VA
PA
WV
PA
WA
KY
MD
MI
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 8,549.14
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 8,549.14
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 1,295.15
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 1,295.15
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
7 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
HARPER HUTZEL HOSPITAL MI
HARRINGTON MEMORIAL HOSPITAL HARRIS METHODIST HEB HOSP TX
HARRISON COUNTY COMM HSP MO
HARTFORD HOSP CT
HAZLETON GEN HSP PA
HCA HEALTH SERVICES OF TENN
HCA OAK HILL HOSP FL
HEALTH ALLIANCE HOSP
HEALTH PARK MEDICAL CENTER FL
HEALTHSOUTH REHAB HOSP ERIE
HEART HOSPITAL BAYLOR PLANO T
HELEN ELLIS MEM HSP FL
HENRY FORD HOSPITAL MI
HENRY FORD WYANDOTTE HOSPITAL
HENRY HEYWOOD MEM HOSP MA
HERITAGE HOSPITAL NC
HIALEAH HOSPITAL FL
HIGH POINT REG HEALTH SYS NC
HIGHLANDS HSP&HLTH CENTER
HIGHLINE MEDICAL CENTER WA
HILLCREST MEMORIAL HOSP SC
HOBOKEN UNIV MED CTR NJ
HOLMES REG MED CTR FL
HOLSTON VALLEY MEDICAL CENTER
HOLY CROSS HOSPITAL IL
HOLY CROSS HOSPITAL NM
HOLY CROSS HSP FL
HOLY NAME HOSPITAL NJ
HOLY SPIRIT HOSPITAL
HOLYOKE HOSP MA
HOMESTEAD HOSPITAL FL
HORIZON HSP SYSTMS PA
HOSPITAL CORP/LAKEVIEW HSP UT
HOSPITAL OF ST RAPHAEL CT
HOSPITAL OF THE UNIV OF PENN
HOWARD CTY GENERAL HSP MD
HSP CENTRAL CT NEW BRIT
HUGULEY MEMORIAL HOSPITAL TX
HUMBOLDT GENERAL HSP NV
HUNTERDON MEDICAL CENTER
HUNTSVILLE HOSPITAL AL
HURLEY MED CTR MI
ILLINOIS MASONIC MED CTR IL
IMPERIAL POINT HSP FL
INDIANA REGIONAL MEDICAL CENT
INGALLS MEMORIAL HOSPITAL IL
INGHAM REGIONAL MEDICAL CENTE
INOVA ALEXANDRIA HSP VA
City, State
DETROIT
SOUTHBRIDGE
BEDFORD
BETHANY
HARTFORD
HAZLETON
SMYRNA
BROOKSVILLE
LEOMINSTER
FORT MYERS
ERIE
PLANO
TARPON SPRINGS
DETROIT
WYANDOTTE
GARDNER
TARBORO
HIALEAH
HIGH POINT
CONNELLSVILLE
BURIEN
SIMPSONVILLE
HOBOKEN
MELBOURNE
KINGSPORT
CHICAGO
TAOS
FT LAUDERDALE
TEANECK
CAMP HILL
HOLYOKE
HOMESTEAD
GREENVILLE
BOUNTIFUL
NEW HAVEN
PHILADELPHIA
COLUMBIA
NEW BRITAIN
FT WORTH
WINNEMUCCA
FLEMINGTON
HUNTSVILLE
FLINT
CHICAGO
FT LAUDERDALE
INDIANA
HARVEY
LANSING
ALEXANDRIA
MI
MA
TX
MO
CT
PA
TN
FL
MA
FL
PA
TX
FL
MI
MI
MA
NC
FL
NC
PA
WA
SC
NJ
FL
TN
IL
NM
FL
NJ
PA
MA
FL
PA
UT
CT
PA
MD
CT
TX
NV
NJ
AL
MI
IL
FL
PA
IL
MI
VA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 8,549.14
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 7,101.21
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 1,295.15
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
8 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
INTEGRIS BAPTIST MED CTR OK
INTERMOUNTAIN MEDICAL CENTER IOWA METHODIST MED CTR IA
IREDELL MEMORIAL HOSPITAL NC
JACKSON COUNTY MEM OK
JACKSON MADISON CTY GEN TN
JACKSON MEM HSP FL
JAMES LAWRENCE KERNAN HOSPITA
JASPER COUNTY HOSPITAL IN
JAY HSP FL
JEANES HOSPITAL PA
JEFFERSON MEMORIAL HOSP MO
JENNIE EDMUNDSON MEM HOSP IA
JENNIE STUART MED CTR KY
JERSEY CITY MEDICAL CTR NJ
JERSEY SHORE MEDICAL CTR NJ
JEWISH HOSPITAL KY
JOHN C LINCOLN DEERVALLEY AZ
JOHN C LINCOLN HOSP HLTH AZ
JOHN DEMPSEY HOSPITAL UNIV CT
JOHN F KENNEDY MED CTR
JOHNS HOPKINS BAYVIEW MED MD
JOHNS HOPKINS HOSPITAL MD
JOHNSON MEM HSP
JORDAN HOSPITAL MA
JUPITER MEDICAL CENTER FL
KAPIOLANI MED PALI MOMI HI
KENDALL REG MED CTR FL
KENNEDY KRIEGER INSTITUTE MD
KENNEDY MEM HOSP/CHERRY HILL
KENNEDY MEM HOSP/UMC STRATFOR
KENNEDY MEM HOSP/WASHINGTON
KENT COUNTY MEMORIAL HOSPITAL
KERN MEDICAL CTR CA
KERSHAW CTY MED CTR SC
KESSLER INSTITUTE FOR REHAB
KINGMAN REGIONAL MED CTR AZ
LAFAYETTE HOME HOSPITAL IN
LAKE POINTE MEDICAL CENTER TX
LAKELAND HSP ST JOSEPH MI
LAKELAND REG MED CTR FL
LAKES REGION GEN HOSP‐FRNKLIN
LAKES REGION GEN HOSP‐LACONIA
LAKEWOOD HSP OH
LANCASTER GENERAL HOSP PA
LANCASTER HSP CRP‐SPRING MEM
LANDMARK MEDICAL CENTER RI
LAREDO TEXAS HOSP TX
LARGO MEDICAL CENTER FL
City, State
OKLAHOMA CITY
MURRAY
DES MOINES
STATESVILLE
ALTUS
JACKSON
MIAMI
BALTIMORE
RENSSELAER
JAY
PHILADELPHIA
FESTUS
COUNCIL BLUFFS
HOPKINSVILLE
JERSEY CITY
NEPTUNE
LOUISVILLE
PHOENIX
PHOENIX
FARMINGTON
EDISON
BALTIMORE
BALTIMORE
STAFFORD SPRINGS
PLYMOUTH
JUPITER
AIEA
MIAMI
BALTIMORE
CHERRY HILL
STRATFORD
TURNERSVILLE
WARWICK
BAKERSFIELD
CAMDEN
WEST ORANGE
KINGMAN
LAFAYETTE
ROWLETT
SAINT JOSEPH
LAKELAND
FRANKLIN
LACONIA
LAKEWOOD
LANCASTER
LANCASTER
WOONSOCKET
LAREDO
LARGO
OK
UT
IA
NC
OK
TN
FL
MD
IN
FL
PA
MO
IA
KY
NJ
NJ
KY
AZ
AZ
CT
NJ
MD
MD
CT
MA
FL
HI
FL
MD
NJ
NJ
NJ
RI
CA
SC
NJ
AZ
IN
TX
MI
FL
NH
NH
OH
PA
SC
RI
TX
FL
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 8,549.14
$ 8,549.14
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 8,549.14
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 7,101.21
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 1,295.15
$ 1,295.15
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 1,295.15
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
9 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
LAS PALMAS MED CTR TX
LAWRENCE & MEMORIAL HOSPS CT
LAWRENCE GEN HOSP MA
LDS HOSPITAL UT
LEE MEM HOSP FL
LEESBURG REG MED CTR FL
LEGACY EMANUEL HOSPITAL
LEGACY GOOD SAMARITAN HSP OR
LEGACY MOUNT HOOD MED CTR OR
LEHIGH VALLEY HOSP CTR PA
LEHIGH VALLEY MUHLENBERG PA
LESTER E COX MEDICAL CENTER
LEXINGTON MEDICAL CENTER SC
LIBERTY HOSPITAL MO
LITTLE COLORADO MED CTR
LITTLETON REGIONAL HOSP NH
LOCK HAVEN HOSPITAL PA
LODI MEM HSP CA
LOGAN REG HOSP UT
LONG BEACH MEM MED CTR CA
LONGMONT UNITED HOSPITAL CO
LOS ANGELES COUNTY MED CTR CA
LOS COLINAS MEDICAL CENTER TX
LOUDOUN HOSPITAL CENTER VA
LOUIS A WEISS MEMORIAL HOSP I
LOURDES MED CTR BURLINGTON CT
LOWELL GENERAL HOSPITAL MA
LUTHER HSP WI
LUTHERAN MEDICAL CENTER OH
LYNCHBURG GENERAL HOSP VA
MACNEAL HOSPITAL IL
MAGEE REHAB HOSPITAL‐PA
MAGEE WOMENS HOSPITAL PA
MAIN LINE HSP LANKENAU PA
MAINE GEN MED CTR ME
MAINE MED CTR ME
MANATEE MEMORIAL HSP FL
MARIAN COMMUNITY HOSPITAL PA
MARICOPA MEDICAL CENTER AZ
MARINERS HOSPITAL FL
MARLBOROUGH HOSP MA
MARTHAS VINEYARD HOSPITAL MA
MARTIN MEMORIAL MED CTR FL
MARY HITCHCOCK MEM HOSP NH
MARY IMMACULATE HOSPITAL VA
MARY LANNING MEM HSP NE
MARY WASHINGTON HOSPITAL VA
MARYMOUNT HOSPITAL OH
MARYVIEW MEDICAL CENTER VA
City, State
EL PASO
NEW LONDON
LAWRENCE
SALT LAKE CITY
FORT MYERS
LEESBURG
PORTLAND
PORTLAND
GRESHAM
ALLENTOWN
BETHLEHEM
SPRINGFIELD
WEST COLUMBIA
LIBERTY
WINSLOW
LITTLETON
LOCK HAVEN
LODI
LOGAN
LONG BEACH
LONGMONT
LOS ANGELES
IRVING
LEESBURG
CHICAGO
WILLINGBORO
LOWELL
EAU CLAIRE
CLEVELAND
LYNCHBURG
BERWYN
PHILADELPHIA
PITTSBURGH
WYNNEWOOD
WATERVILLE
PORTLAND
BRADENTON
CARBONDALE
PHOENIX
TAVERNIER
MARLBOROUGH
OAK BLUFFS
STUART
LEBANON
NEWPORT NEWS
HASTINGS
FREDERICKSBURG
CLEVELAND
PORTSMOUTH
TX
CT
MA
UT
FL
FL
OR
OR
OR
PA
PA
MO
SC
MO
AZ
NH
PA
CA
UT
CA
CO
CA
TX
VA
IL
NJ
MA
WI
OH
VA
IL
PA
PA
PA
ME
ME
FL
PA
AZ
FL
MA
MA
FL
NH
VA
NE
VA
OH
VA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
10 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
MASSACHUSETTS GEN HOSP
MAURY REGIONAL HSP TN
MAYO CLINIC FLORIDA
MCKAY DEE HOSPITAL CTR UT
MCKEE MED CTR CO
MCLEOD LORIS SEACOAST HSP SC
MCLEOD MEDICAL CTR DILLON
MCLEOD REG MED CTR SC
MEADOWLANDS HOSP MED CTR NJ
MEADVILLE MEDICAL CENTER PA
MEDCENTRAL HLTH SYS OH
MEDICAL CENTER AT PRINCETON
MEDICAL CENTER HOSPITAL TX
MEDICAL CENTER OF MANCHESTER
MEDICAL CENTER OF MC KINNEY T
MEDICAL CENTER OF PLANO TX
MEDICAL CITY DALLAS HOSP TX
MEDICAL CTR CENTRAL GEORGIA G
MEDICAL CTR OF ARLINGTON TX
MEDICAL CTR OF OCEAN CO.
MEDICAL UNIVERSITY HSP OF SC
MEDINA GEN HSP OH
MELROSE WAKEFIELD HSP MA
MEMORIAL HERMANN HOSP TX
MEMORIAL HERMANN KATY HOSPITA
MEMORIAL HERMANN SE & SW HOSP
MEMORIAL HLTH UNIV MED CTR GA
MEMORIAL HOSP OF SALEM NJ
MEMORIAL HOSP PEMBROKE FL
MEMORIAL HOSPITAL BURLINGTON
MEMORIAL HOSPITAL IL
MEMORIAL HOSPITAL MIRAMAR FL
MEMORIAL HOSPITAL PA
MEMORIAL HOSPITAL PA INC
MEMORIAL HOSPITAL RI
MEMORIAL HOSPITAL SOUTH BEND
MEMORIAL HOSPITAL WEST FL
MEMORIAL HSP CO
MEMORIAL HSP MARTINSVILLE VA
MEMORIAL HSP OF EASTON MD INC
MEMORIAL MED CTR IL
MEMORIAL MISSION HOSPITAL NC
MEMORIAL REG HSP FL
MERCY FITZGERALD HOSPITAL PA
MERCY HOSP OF PHILADELPHIA
MERCY HSP GRAYLING MI
MERCY HSP MN
MERCY HSP TIFFIN OH
MERCY HSP WILLARD OH
City, State
BOSTON
COLUMBIA
JACKSONVILLE
OGDEN
LOVELAND
LORIS
DILLON
FLORENCE
SECAUCUS
MEADVILLE
MANSFIELD
PRINCETON
ODESSA
MANCHESTER
MCKINNEY
PLANO
DALLAS
MACON
ARLINGTON
BRICK
CHARLESTON
MEDINA
MELROSE
HOUSTON
KATY
HOUSTON
SAVANNAH
SALEM
PEMBROKE PINES
MOUNT HOLLY
BELLEVILLE
MIRAMAR
YORK
TOWANDA
PAWTUCKET
SOUTH BEND
PEMBROKE PINES
COLORADO SPRINGS
MARTINSVILLE
EASTON
SPRINGFIELD
ASHEVILLE
HOLLYWOOD
DARBY
PHILADELPHIA
GRAYLING
COON RAPIDS
TIFFIN
WILLARD
MA
TN
FL
UT
CO
SC
SC
SC
NJ
PA
OH
NJ
TX
TN
TX
TX
TX
GA
TX
NJ
SC
OH
MA
TX
TX
TX
GA
NJ
FL
NJ
IL
FL
PA
PA
RI
IN
FL
CO
VA
MD
IL
NC
FL
PA
PA
MI
MN
OH
OH
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 7,101.21
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
11 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
MERCY MED CTR N IOWA
MERCY MED CTR WI
MERCY MEDICAL CENTER MA
MERCY MEDICAL CENTER MD
MERCY MEDICAL CENTER OR
MERCY MEMORIAL HOSPITAL MI
MERCY ST VINCENT MED CTR OH
MERCY SUBURBAN HSP PA
MERIDIA EUCLID HSP OH
MERIDIA HILLCREST HSP OH
MERIDIA HURON HSP OH
MERIT MOUNTAINSIDE HOSP NJ
MERITER HOSP INC WI
MERRIMACK VALLEY HSP MA
METHODIST HOSP OF MEMPHIS TN
METHODIST HS NORTH/SOUTH IN
METHODIST IU RILEY HOSPITAL METRO HEALTH SYSTEM OH
METRO WEST MEDICAL CENTER MA
METROPLEX HOSPITAL TX
MIAMI CHILDRENS HOSPITAL FL
MIAMI VALLEY HOSPITAL OH
MID MICHIGAN REG MED CTR MI
MID VALLEY HOSPITAL ASSOC
MIDDLESEX HOSPITAL CT
MIDDLETOWN REGIONAL HOSPITAL MIDSTATE MEDICAL CENTER CT
MIDWEST CITY REGIONAL HOSP OK
MILES MEMORIAL HOSPITAL ME
MILFORD HOSPITAL CT
MILLCREEK COMMUNITY HOSPITAL
MILLINOCKET REGIONAL HSP ME
MILTON S HERSHEY MED CTR PA
MIMBRES MEMORIAL HOSP NM
MIRIAM HOSPITAL RI
MONADNOCK COMMUNITY HOSPITAL
MONMOUTH MEDICAL CENTER NJ
MONTGOMERY GENERAL HOSP MD
MONTGOMERY HOSPITAL PA
MONTROSE GENERAL HSP
MOREHEAD MEM HSP NC
MORGAN COUNTY MEM HOSPITAL IN
MOSES H CONE HOSPITAL NC
MOSES TAYLOR HOSPITAL
MOUNT CARMEL EAST OH
MOUNT SINAI MEDICAL CTR OF FL
MT ASCUTNEY HOSP AND HLTH CTR
MT CARMEL WEST HOSPITAL OH
MT GRAHAM REG MED CTR AZ
City, State
MASON CITY
OSHKOSH
SPRINGFIELD
BALTIMORE
ROSEBURG
MONROE
TOLEDO
NORRISTOWN
EUCLID
MAYFIELD HTS
EAST CLEVELAND
MONTCLAIR
MADISON
HAVERHILL
MEMPHIS
GARY
INDIANAPOLIS
CLEVELAND
FRAMINGHAM
KILLEEN
MIAMI
DAYTON
MIDLAND
PECKVILLE
MIDDLETOWN
MIDDLETOWN
MERIDEN
MIDWEST CITY
DAMARISCOTTA
MILFORD
ERIE
MILLINOCKET
HERSHEY
DEMING
PROVIDENCE
PETERBOROUGH
OCEANPORT
OLNEY
NORRISTOWN
MONTROSE
EDEN
MARTINSVILLE
GREENSBORO
SCRANTON
COLUMBUS
MIAMI BEACH
WINDSOR
COLUMBUS
SAFFORD
IA
WI
MA
MD
OR
MI
OH
PA
OH
OH
OH
NJ
WI
MA
TN
IN
IN
OH
MA
TX
FL
OH
MI
PA
CT
OH
CT
OK
ME
CT
PA
ME
PA
NM
RI
NH
NJ
MD
PA
PA
NC
IN
NC
PA
OH
FL
VT
OH
AZ
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 8,549.14
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 8,549.14
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 1,295.15
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 1,295.15
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
12 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
MUNROE REGIONAL MED CTR FL
NACOGDOCHES MEM HSP TX
NANTICOKE MEMORIAL HOSPITAL
NAPLES COMMUNITY HOSPITAL FL
NASH GENERAL HOSPITAL NC
NASHOBA VALLEY MED CTR MA
NASHVILLE MEM HSP TN
NASON HOSPITAL PA
NATCHEZ REGIONAL MED CNTR MS
NATIONAL HSP KIDS IN CRISIS P
NAZARETH HOSPITAL PA
NEBRASKA MEDICAL CENTER NE
NEW MILFORD HSP
NEW PT RICHEY/MED CTR OF TRIN
NEWPORT HSP RI
NEWTON MEMORIAL HOSPITAL NJ
NEWTON WELLESLEY HOSP MA
NORTH ADAMS REG HOSP MA
NORTH BAY MEDICAL CTR CA
NORTH BROWARD MEDICAL CTR FL
NORTH CAROLINA BAPTIST HSP
NORTH COLORADO MED CTR CO
NORTH COUNTRY HOSPITAL VT
NORTH FULTON MED CTR GA
NORTH HILLS HOSPITAL TX
NORTH MEM MED CTR MN
NORTH OKLALOOSA MED CTR FL
NORTH PHILADELPHIA HLTH SYS
NORTH SHORE MED CTR FL
NORTH SHORE MED CTR FMC FL
NORTH SUBURBAN MED CTR CO
NORTH VISTA HOSPITAL NV
NORTHEAST ALABAMA REG MED
NORTHERN COCHISE COMM HSP AZ
NORTHERN HOSP OF SURRY CO NC
NORTHSHORE UNIVERSITY HEALTH NORTHSIDE HOSP FL
NORTHSIDE HOSP GA
NORTHWEST HOSPITAL CENTER MD
NORTHWEST MED CTR AZ
NORTHWEST TEXAS HOSPITAL
NORTHWESTERN MEDICAL CTR VT
NORTON HOSPITAL KY
NORWALK HOSPITAL
NORWOOD HOSP INC MA
OAK VALLEY HOSPITAL DISTRICT OAKWOOD HOSP HERITAGE CTR MI
OAKWOOD HOSPITAL MI
OCEAN BEACH HOSPITAL WA
City, State
OCALA
NACOGDOCHES
SEAFORD
NAPLES
ROCKY MOUNT
AYER
MADISON
ROARING SPRING
NATCHEZ
OREFIELD
PHILADELPHIA
OMAHA
NEW MILFORD
TRINITY
NEWPORT
NEWTON
NEWTON
NORTH ADAMS
FAIRFIELD
POMPANO BEACH
WINSTON SALEM
GREELEY
NEWPORT
ROSWELL
NORTH RICHLAND HILLS
ROBBINSDALE
CRESTVIEW
PHILADELPHIA
MIAMI
FT LAUDERDALE
THORNTON
N LAS VEGAS
ANNISTON
WILLCOX
MOUNT AIRY
EVANSTON
ST PETERSBURG
ATLANTA
RANDALLSTOWN
TUCSON
AMARILLO
SAINT ALBANS
LOUISVILLE
NORWALK
NORWOOD
OAKDALE
TAYLOR
DEARBORN
ILWACO
FL
TX
DE
FL
NC
MA
TN
PA
MS
PA
PA
NE
CT
FL
RI
NJ
MA
MA
CA
FL
NC
CO
VT
GA
TX
MN
FL
PA
FL
FL
CO
NV
AL
AZ
NC
IL
FL
GA
MD
AZ
TX
VT
KY
CT
MA
CA
MI
MI
WA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 7,101.21
$ 5,599.08
$ 5,599.08
$ 7,101.21
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 8,549.14
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 1,295.15
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
13 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
OCHSNER MEDICAL CENTER KENNER
OHIO STATE UNIVERSITY HSP OH
OHIO VALLEY MED CTR WV
OLATHE MEDICAL CENTER KS
OLYMPIC MEDICAL CTR WA
ORLANDO REG HLTH SYS FL
OSCEOLA REG HOSP FL
OU MEDICAL CENTER OK
OUR LADY OF LOURDES MED CTR N
OUTER BANKS HSP THE NC
PALISADES MEDICAL CENTER NJ
PALM BAY HOSPITAL FL
PALM BEACH GARDENS AND MED CT
PALMERTON HOSPITAL PA
PALMETTO GENERAL HOSPITAL FL
PALMETTO HEALTH ALLIANCE SC
PALMYRA PARK HSP GA
PAOLI MEMORIAL HOSPITAL
PARK PLAZA HOSPITAL TX
PARKER ADVENTIST HEALTH CO
PARKLAND MEDICAL CTR NH
PARKLAND MEM HOSP TX
PARKVIEW HSP ME
PARKVIEW MED CTR CO
PARKWEST MEDICAL CENTER TN
PARRISH MED CTR FL
PENINSULA REGIONAL MEDICAL CT
PENNSYLVANIA HOSP PA
PENOBSCOT BAY MED CTR ME
PERSON COUNTY MEM HOSP NC
PETERSON REGIONAL MEDICAL CEN
PHOEBE SUMTER MED CTR GA
PHOENIX BAPTIST HOSP AZ
PHOENIX CHILDRENS HSP AZ
PHOENIXVILLE HOSP COMP PA
PIEDMONT MED CTR SC
PINNACLE HEALTH HOSPITALS PA
PITT COUNTY MEMORIAL HOSP NC
PLANTATION GENERAL HOSP FL
POCONO MED CTR PA
POMONA VALLEY HOSPITAL MED CT
PORTER MEDICAL CENTER INC
PORTERCARE ADVENTIST HLTH CO
POTOMAC HSP OF PRINCE WILL VA
POTOMAC VALLEY HSP OF WEST VA
POTTSTOWN MEM MED CTR PA
POUDRE VALLEY HSP CO
PRESBYTERIAN HOSP MATTHEWS NC
PRESBYTERIAN HOSP NM
City, State
KENNER
COLUMBUS
WHEELING
OLATHE
PORT ANGELES
ORLANDO
KISSIMMEE
OKLAHOMA CITY
CAMDEN
NAGS HEAD
NORTH BERGEN
PALM BAY
PALM BEACH GARDENS
PALMERTON
HIALEAH
COLUMBIA
ALBANY
PAOLI
HOUSTON
PARKER
DERRY
DALLAS
BRUNSWICK
PUEBLO
KNOXVILLE
TITUSVILLE
SALISBURY
PHILADELPHIA
ROCKPORT
ROXBORO
KERRVILLE
AMERICUS
PHOENIX
PHOENIX
PHOENIXVILLE
ROCK HILL
HARRISBURG
GREENVILLE
PLANTATION
E STROUDSBURG
POMONA
MIDDLEBURY
LITTLETON
WOODBRIDGE
KEYSER
POTTSTOWN
FORT COLLINS
MATTHEWS ALBUQUERQUE
LA
OH
WV
KS
WA
FL
FL
OK
NJ
NC
NJ
FL
FL
PA
FL
SC
GA
PA
TX
CO
NH
TX
ME
CO
TN
FL
MD
PA
ME
NC
TX
GA
AZ
AZ
PA
SC
PA
NC
FL
PA
CA
VT
CO
VA
WV
PA
CO
NC
NM
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 7,101.21
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
14 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
PRESBYTERIAN HOSPITAL NC
PRESBYTERIAN HSP OF DALLAS
PRESBYTERIAN INTERCOMM HSP CA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRESBYTERIAN UNIV HSP PA
PRESTON MEMORIAL HOSP WV
PRIMARY CHILDRENS MED CTR UT
PRINCE GEORGES HOSP CTR MD
PRINCETON COMMUNITY HOSP WV
PROVIDENCE HEALTH CTR TX
PROVIDENCE HOSPITAL MA
PROVIDENCE MEMORIAL HOSPITAL PROVIDENCE PORTLAND MED OR
PROVIDENCE ST PETERS HOSP WA
QUEENS MEDICAL CENTER HI THE
QUINCY MED CTR MA
R E THOMASON GENERAL HOSP TX
RALEIGH GENERAL HOSPITAL WV
RAMAPO RIDGE PSYCH HOSP
RAPID CITY REGIONAL HOSP SD
RARITAN BAY HEALTH SERVICES
READING HOSP & MED CTR
REDINGTON FAIRVIEW GEN HSP ME
REFUGIO COUNTY MEM HSP TX
REG CTR ORANGEBURG CALHOUN SC
REGIONAL HSP SCRANTON PA
REGIONAL MED CTR AT MEMPHIS
REGIONAL MED CTR BAYONET FL
REGIONS HOSPITAL MN
RENOWN REG MED CTR NV
RENOWN SOUTH MEADOWS MED CTR
RESEARCH MED CTR MO
REX HOSPITAL NC
RHODE ISLAND HOSPITAL RI
RIDDLE MEMORIAL HOSP PA
RIVERSIDE COUNTY MED CTR CA
RIVERSIDE METH HOSP/OHIO HLTH
RIVERSIDE REG MED CTR VA
RIVERSIDE TAPPAHANNOCK HSP VA
RIVERSIDE WALTER REED HSP VA
RIVERTON HOSPITAL UT
RIVERVIEW HOSPITAL NJ
ROANOKE CHOWAN HOSPITAL NC
ROBERT PACKER HOSP PA
ROBERT W JOHNSON UNIV HSP RAH
ROBERT WOOD JOHNSON UNIV HSP
City, State
CHARLOTTE
DALLAS
WHITTIER
PITTSBURGH
PITTSBURGH
PITTSBURGH
PITTSBURGH
PITTSBURGH
KINGWOOD
SALT LAKE CITY
CHEVERLY
PRINCETON
WACO
HOLYOKE
EL PASO
PORTLAND
OLYMPIA
HONOLULU
QUINCY
EL PASO
BECKLEY
WYCKOFF
RAPID CITY
PERTH AMBOY
READING
SKOWHEGAN
REFUGIO
ORANGEBURG
SCRANTON
MEMPHIS
HUDSON
SAINT PAUL
RENO
RENO
KANSAS CITY
RALEIGH
PROVIDENCE
MEDIA
MORENO VALLEY
COLUMBUS
NEWPORT NEWS
TAPPAHANNOCK
GLOUCESTER
RIVERTON
RED BANK
AHOSKIE
SAYRE
RAHWAY
NEW BRUNSWICK
NC
TX
CA
PA
PA
PA
PA
PA
WV
UT
MD
WV
TX
MA
TX
OR
WA
HI
MA
TX
WV
NJ
SD
NJ
PA
ME
TX
SC
PA
TN
FL
MN
NV
NV
MO
NC
RI
PA
CA
OH
VA
VA
VA
UT
NJ
NC
PA
NJ
NJ
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 7,101.21
$ 6,237.93
$ 8,549.14
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 7,101.21
$ 5,599.08
$ 6,237.93
$ 7,101.21
$ 8,549.14
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 1,295.15
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 1,295.15
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 261.20
$ 261.20
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 261.20
$ 261.20
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 676.42
$ 676.42
15 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 137.42
1.0684
0.361252
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
ROCKFORD MEMORIAL HOSPITAL IL
ROCKINGHAM MEMORIAL HSP VA
ROGER WILLIAMS GENERAL HOSP
ROGUE VALLEY MEMORIAL HSP OR
ROLLINS BROOK COMMUNITY HOSPI
ROXBOROUGH MEMORIAL HOSPITAL RUTLAND REG MED CTR
SACRED HEART HOSPITAL PA
SACRED HEART MED CTR UNIV DIS
SAINT BARNABAS MEDICAL CENTER
SAINT FRANCIS HOSPITAL TN
SAINT LUKES SOUTH HSP INC KS
SAINT VINCENTS HLTH CTR
SAINTS MEDICAL CENTER MA
SAINTS MEM MED CTR MA
SALINA REG HLTH CTR KS
SAN ANTONIO COMM HSP CA
SAN JOAQUIN COMMUNITY HOSPITA
SAN RAMON MEDICAL CTR CA
SANFORD JACKSON HOSP MN
SARASOTA MEMORIAL HOSPITAL FL
SCHUYLKILL MED CTR SOUTH PA
SCOTTSDALE HLTHCARE SHEA AZ
SCOTTSDALE MEM HSP AZ
SCRIPPS MERCY HSP CHULA VISTA
SELF REG HEALTHCARE SC
SENTARA BAYSIDE HOSP VA
SENTARA CAREPLEX HOSPITAL VA
SENTARA HOSPITAL VA
SENTARA LEIGH HSP VA
SENTARA NORFOLK HSP VA
SENTARA VIRGINIA BEACH GEN HS
SENTARA WILLIAMSBURG COMM HOS
SETON MED CTR WILLIAMSTON TX
SETON MEDICAL CENTER CA
SETON NORTHWEST HOSPITAL TX
SEVIER VALLEY MEDICAL CTR UT
SEWICKLEY VALLEY HOSPITAL PA
SHANDS JACKSONVILLE MED FL
SHANDS TEACHING HOSPITAL FL
SHARON HOSPITAL CT
SHARP CHULA VISTA
SHARP MEM HSP CA
SHELBY CTY/WILSON MEMORIAL OH
SHERMAN OAKS HSP CA
SHORE MEMORIAL HOSPITAL
SHRINERS HSP FOR CHILDREN PA
SILVER CROSS HOSPITAL IL
SINAI GRACE HOSPITAL MI
City, State
ROCKFORD
HARRISONBURG
PROVIDENCE
MEDFORD
LAMPASAS
PHILADELPHIA
RUTLAND
ALLENTOWN
EUGENE
OCEAN PORT
MEMPHIS
OVERLAND PARK
ERIE
LOWELL
LOWELL
SALINA
UPLAND
BAKERSFIELD
SAN RAMON
JACKSON
SARASOTA
POTTSVILLE
SCOTTSDALE
SCOTTSDALE
CHULA VISTA
GREENWOOD
VIRGINIA BEACH
HAMPTON
SUFFOLK
NORFOLK
NORFOLK
VIRGINIA BEACH
WILLIAMSBURG
ROUND ROCK
DALY CITY
AUSTIN
RICHFIELD
SEWICKLEY
JACKSONVILLE
GAINESVILLE
SHARON
CHULA VISTA
SAN DIEGO
SIDNEY
SHERMAN OAKS
SOMERS POINT
PHILADELPHIA
JOLIET
DETROIT
IL
VA
RI
OR
TX
PA
VT
PA
OR
NJ
TN
KS
PA
MA
MA
KS
CA
CA
CA
MN
FL
PA
AZ
AZ
CA
SC
VA
VA
VA
VA
VA
VA
VA
TX
CA
TX
UT
PA
FL
FL
CT
CA
CA
OH
CA
NJ
PA
IL
MI
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 7,101.21
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
16 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
SINAI‐GRACE HOSPITAL MI
SKAGGS COMM HEALTH MO
SMYTH COUNTY COMMUNITY HOSP
SOLDIERS AND SAILORS MEM HOSP
SOMERSET MED CENTER NJ
SOUTH BAY HOSP FL
SOUTH CENTRAL REG MED CTR MS
SOUTH COUNTY HOSPTAL RI
SOUTH FLORIDA BAPTIST HSPFL
SOUTH FULTON MEDICAL CR GA
SOUTH LAKE HSP FL
SOUTH MIAMI HOSPITAL FL
SOUTH POINTE HOSPITAL OH
SOUTH SHORE HOSP MA
SOUTHCREST HSP OK
SOUTHEASTERN OHIO REG MED CTR
SOUTHEASTERN REG MED CTR NC
SOUTHERN HILLS M C TN
SOUTHERN MAINE MEDICAL CENTER
SOUTHERN MARYLAND HOSP INC
SOUTHERN OCEAN MED CTR NJ
SOUTHERN OHIO MED CTR OH
SOUTHSIDE COMM HOSP VA
SOUTHWEST GEN HSP TX
SOUTHWEST GENERAL HOSPITAL
SOUTHWEST MEM HSP CO
SOUTHWEST WASHINGTON MED WA
SOUTHWESTERN VT MED CTR INC
SPARTANBURG REG MED CTR SC
SPEARE MEMORIAL HOSP NH
SPRINGFIELD KINDRED PARKVIEW
SSM ST MARYS HLTH CTR MO
ST ALPHONSUS REG MED CTR ID
ST ANTHONY SUMMIT HOSPITAL CO
ST CATHERINE HSP IN
ST CHRISTOPHERS HSP CHILD PA
ST CLARES HOSPITAL
ST CLOUD HOSPITAL
ST DOMINIC JACKSON MEM HOSP
ST ELIZABETH HEALTH CENTER OH
ST ELIZABETH HSP WI
ST ELIZABETH MED CTR KY
ST FRANCIS HOSP & MED CTR CT
ST FRANCIS HOSPITAL OK
ST FRANCIS MEDICAL CENTER
ST FRANCIS MEDICAL CENTER MN
ST FRANCIS MEDICAL CENTER NE
ST JAMES HLTH CAREHSP MT
ST JOHNS HOSP IL
City, State
DETROIT
BRANSON
MARION
WELLSBORO
SOMERVILLE
SUN CITY CENTER
LAUREL
WAKEFIELD
PLANT CITY
EAST POINT
CLERMONT
SOUTH MIAMI
WARRENSVILLE HTS
SOUTH WEYMOUTH
TULSA
CAMBRIDGE
LUMBERTON
NASHVILLE
BIDDEFORD
CLINTON
MANAHAWKIN
PORTSMOUTH
FARMVILLE
SAN ANTONIO
CLEVELAND
CORTEZ
VANCOUVER
BENNINGTON
SPARTANBURG
PLYMOUTH
SPRINGFIELD
SAINT LOUIS
BOISE
FRISCO
EAST CHICAGO
PHILADELPHIA
DENVILLE
SAINT CLOUD
JACKSON
YOUNGSTOWN
APPLETON
EDGEWOOD
HARTFORD
TULSA
TRENTON
BRECKENRIDGE
GRAND ISLAND
BUTTE
SPRINGFIELD
MI
MO
VA
PA
NJ
FL
MS
RI
FL
GA
FL
FL
OH
MA
OK
OH
NC
TN
ME
MD
NJ
OH
VA
TX
OH
CO
WA
VT
SC
NH
MA
MO
ID
CO
IN
PA
NJ
MN
MS
OH
WI
KY
CT
OK
NJ
MN
NE
MT
IL
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
17 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
ST JOHNS MERCY MED CTR MO
ST JOHNS REG HLTH CTR MO
ST JOHNS REGIONAL MED CTR MO
ST JOSEPH HOSPITAL PA
ST JOSEPH HOSPITAL WA
ST JOSEPH MERCY HSP OAKLAND
ST JOSEPHS HLTH SVCS RI
ST JOSEPHS HOSP MED CTR NJ
ST JOSEPHS HOSPITAL GA
ST JOSEPHS HOSPITAL GA
ST JOSEPHS REG MED CTR IN
ST JUDE CHILDRENS RES HSP TN
ST LOUIS CHILDRENS HOSP MO
ST LUKES COMM MC WOODLANDS TX
ST LUKES EAST LEES HSP MO
ST LUKES EPISCOPAL HSP TX
ST LUKES HOSP WEST KY
ST LUKES HOSPITAL
ST LUKES HOSPITAL
ST LUKES HOSPITAL MA
ST LUKES HOSPITAL OH
ST LUKES MED CTR AZ
ST LUKES NORTHLAND HSP MO
ST MARGARET MERCY HLTH IN
ST MARKS HOSPITAL UT
ST MARY HOSPITAL PA
ST MARY MERCY HSP MI
ST MARYS HEALTH SYS TN
ST MARYS HOSP NJ
ST MARYS HOSPITAL OF CONN
ST MARYS HSP VA
ST MARYS MED CTR EVANSVLLE IN
ST MARYS MED CTR IN
ST MARYS MEDICAL CENTER FL
ST MARYS REG MED CENTER ME
ST MICHAEL MED CENTER NJ
ST PETERS UNIV HSP NJ
ST PETERSBURG GEN HSP FL
ST RITAS MEDICAL CENTER OH
ST ROSE DOMIN HOSP SIENA NV
ST ROSE HOSPITAL CA
ST VINCENT HOSPITAL MA
ST VINCENT HSP INDIANAPOLIS I
ST VINCENTS MEDICAL CENTER CT
STAFFORD HOSPITAL VA
STAMFORD HOSPITAL CT
STANLY MEMORIAL HOSPITAL NC
STEPHENS MEMORIAL HSP
STEVENS HOSPITAL WA
City, State
SAINT LOUIS
SPRINGFIELD
JOPLIN
READING
BELLINGHAM
PONTIAC
NORTH PROVIDENCE
PATERSON
ATLANTA
SAVANNAH
MISHAWAKA
MEMPHIS
SAINT LOUIS
THE WOODLANDS
LEES SUMMIT
HOUSTON
FLORENCE
BETHLEHEM
MILWAUKEE
FALL RIVER
MAUMEE
PHOENIX
SMITHVILLE
DYER
SALT LAKE CITY
LANGHORNE
LIVONIA
KNOXVILLE
PASSAIC
WATERBURY
RICHMOND
EVANSVILLE
HOBART
WEST PALM BEACH
LEWISTON
NEWARK
NEW BRUNSWICK
ST PETERSBURG
LIMA
HENDERSON
HAYWARD
WORCESTER
INDIANAPOLIS
BRIDGEPORT
STAFFORD
STAMFORD
ALBEMARLE
NORWAY
EDMONDS
MO
MO
MO
PA
WA
MI
RI
NJ
GA
GA
IN
TN
MO
TX
MO
TX
KY
PA
WI
MA
OH
AZ
MO
IN
UT
PA
MI
TN
NJ
CT
VA
IN
IN
FL
ME
NJ
NJ
FL
OH
NV
CA
MA
IN
CT
VA
CT
NC
ME
WA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 8,549.14
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 7,101.21
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 8,549.14
$ 7,101.21
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 8,549.14
$ 5,599.08
$ 8,549.14
$ 5,599.08
$ 5,599.08
$ 5,599.08
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 1,295.15
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 1,295.15
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 1,295.15
$ ‐
$ 1,295.15
$ ‐
$ ‐
$ ‐
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
18 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
STEWARD CARNEY HOSP MA
STEWARD GOOD SAM MED CTR MA
STEWARD GOOD SAM MED CTR MA
STEWARD HOLY FAMILY MA
STEWARD NORWOOD HOSP MA
STEWARD ST ANNES HSP MA
STEWARD ST ELIZABETH MED CTR
STILLWATER MEDICAL CENTER OK
STONINGTON INSTITUTE CT
STORMONT VAIL REG MED CTR KS
STS MARY AND ELIZABETH HOSPIT
STURDY MEMORIAL HOSP MA
SUBURBAN HOSPITAL
SUMMERLIN MED CTR NV
SUMMIT MEDICAL CENTER TN
SUN HEALTH BOSWELL HSP AZ
SUNRISE HOSP & MED CTR NV
SWEETWATER HOSP TN
TAMPA GEN HSP DAVIS ISLANDS
TEMPLE LOWER BUCKS HSP PA
TEMPLE UNIVERSITY HOSPITAL
TEXAS CHILDREN'S HOSP TX
TEXAS HLTH ARLINGTON TX
TEXAS HLTH HARRIS METH HSP
TEXAS HLTH PRESBY HOSP PLANO
TEXAS HLTH PRESBYTERIAN HOSP
THOMAS JEFFERSON UNIV HOSP PA
THREE RIVERS COMMUNITY HSP OR
TOLEDO HSP OH
TOWN & COUNTRY HSP FL
TRINITAS HSP NJ
TROY COMMUNITY HOSPITAL
TRUMAN MEDICAL CENTER MO
TRUMBULL MEM HOSP OH
TUCSON MED CTR AZ
TUFTS MEDICAL CENTER MA
TUOMEY REG MED CTR SC
UCSD MEDICAL CENTER
UMASS MEMORIAL MED CNTR PSYCH
UMASS MEMORIAL MEDICAL CENTER
UNDERWOOD MEM HOSP NJ
UNION HOSP OF CECIL CTY MD
UNION MEMORIAL HOSPITAL MD
UNITED HOSPITAL MN
UNITED HSP CTR WV
UNITED MEDICAL HLTHWEST LA
UNITED REG HEALTHCARE SYS TX
UNITY HSP MN
UNIV CA DAVIS MED CTR CA
City, State
DORCHESTER
BROCKTON
BROCKTON
METHUEN
NORWOOD
FALL RIVER
BOSTON
STILLWATER
NORTH STONINGTON
TOPEKA
LOUISVILLE
ATTLEBORO
BETHESDA
LAS VEGAS
HERMITAGE
SUN CITY
LAS VEGAS
SWEETWATER
TAMPA
BRISTOL
PHILADELPHIA
HOUSTON
ARLINGTON
FORTH WORTH
PLANO
ALLEN
PHILADELPHIA
GRANTS PASS
TOLEDO
TAMPA
ELIZABETH
TROY
KANSAS CITY
WARREN
TUCSON
WORCESTER
SUMTER
SAN DIEGO
WORCESTER
WORCESTER
WOODBURY
ELKTON
BALTIMORE
SAINT PAUL
CLARKSBURG
GRETNA
WICHITA FALLS
FRIDLEY
SACRAMENTO
MA
MA
MA
MA
MA
MA
MA
OK
CT
KS
KY
MA
MD
NV
TN
AZ
NV
TN
FL
PA
PA
TX
TX
TX
TX
TX
PA
OR
OH
FL
NJ
PA
MO
OH
AZ
MA
SC
CA
MA
MA
NJ
MD
MD
MN
WV
LA
TX
MN
CA
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 8,549.14
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 1,295.15
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
19 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
UNIV KENTUCKY HOSPITAL
UNIV OF ALABAMA
UNIV OF CHICAGO HOSPITAL IL
UNIV OF HOSPS & CLINICS UMC M
UNIV OF IOWA HSP & CLINICS IA
UNIV OF MED & DENTISTRY OF NJ
UNIV OF NEW MEXICO HOSP NM
UNIV OF NORTH CAROLINA HSP NC
UNIV OF TOLEDO MED CNTR OH
UNIV OF VA MED CTR
UNIV OF WASHINGTON WA
UNIV SO ALABAMA WOMEN&CHILD
UNIV WICSONSIN HSP & CLINICS
UNIVERSITY COMM HOSP FL
UNIVERSITY HOSPITAL GA
UNIVERSITY HSP TX
UNIVERSITY MED CTR TX
UNIVERSITY MEDICAL CENTER AZ
UNIVERSITY MEDICAL CTR CA
UNIVERSITY OF KANSAS HOSPITAL
UNIVERSITY OF MARYLAND MED SY
UNIVERSITY OF MICHIGAN
UNIVERSITY OF TENNESSEE MEM
UNIVERSITY OF UTAH HOSP UT
UNIVERSITY SPECIALTY HOSP MD
UPHS PRESBYTERIAN MEDICAL CEN
UPPER CHESAPEAK MEDICAL CENTE
UPPER CT VALLEY HOSP NH
UPPER VALLEY MEDICAL CTR OH
UT VALLEY REG MED CTR UT
VALLEY HOSPITAL
VALLEY HSP MED CTR NV
VALLEY VIEW HOSP ASSOC CO
VANDERBILT UNIVERSITY HSP TN
VERDE VALLEY MED CTR AZ
VHS CHILDRENS HSP MI
VIERA HOSPITAL FL
VILLAGES REGIONAL HOSP FL
VIRGINIA BEACH PSYCHIATRIC
WACCAMAW COMM HSP SC
WAHIAWA GEN HSP HI
WAKEMED HEALTH AND HOSP NC
WALTON REG MED CTR GA
WARREN GENERAL HOSPITAL PA
WARREN HOSPITAL NJ
WASHINGTON COUNTY HOSPITAL NC
WASHINGTON HOSPITAL PA
WATERBURY HOSPITAL CT
WAUKESHA MEMORIAL HOSPITAL WI
City, State
LEXINGTON
BIRMINGHAM
CHICAGO
JACKSON
IOWA CITY
NEWARK
ALBUQUERQUE
CHAPEL HILL
TOLEDO
CHARLOTTESVILLE
SEATTLE
MOBILE
MADISON
TAMPA
AUGUSTA
SAN ANTONIO
LUBBOCK
TUCSON
FRESNO
KANSAS CITY
BALTIMORE
ANN ARBOR
KNOXVILLE
SALT LAKE CITY
BALTIMORE
PHILADELPHIA
BEL AIR
COLEBROOK
TROY
PROVO
RIDGEWOOD
LAS VEGAS
GLENWOOD SPRINGS
NASHVILLE
COTTONWOOD
DETROIT
MELBOURNE
THE VILLAGES
VIRGINIA BEACH
MURRELLS INLET
WAHIAWA
RALEIGH
MONROE
WARREN
PHILLIPSBURG
PLYMOUTH
WASHINGTON
WATERBURY
WAUKESHA
KY
AL
IL
MS
IA
NJ
NM
NC
OH
VA
WA
AL
WI
FL
GA
TX
TX
AZ
CA
KS
MD
MI
TN
UT
MD
PA
MD
NH
OH
UT
NJ
NV
CO
TN
AZ
MI
FL
FL
VA
SC
HI
NC
GA
PA
NJ
NC
PA
CT
WI
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 8,549.14
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 7,101.21
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 6,237.93
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 1,295.15
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ 298.23
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 261.20
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 676.42
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
20 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 137.42
1.0684
0.361252
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES
EFFECTIVE 04/01/12 ‐ 12/31/12
Hospital Name
WAYNE MEMORIAL HOSP PA
WAYNE MEDICAL CENTER TN
WAYNE MEM HSP NC
WAYNESBORO HSP PA
WEIRTON MEDICAL CTR WV
WELLSTAR COBB HOSP GA
WELLSTAR DOUGLAS HOSP GA
WELLSTAR KENNESTONE HOSP GA
WELLSTAR PAULDING HOSP GA
WEST ALLIS MEMORIAL HOSP WI
WEST GROVE/JENNERSVILLE PA
WEST JEFFERSON MED CTR LA
WEST JERSEY HEALTH SYS
WEST VALLEY HOSPITAL AZ
WESTBOROUGH STATE HOSPITAL MA
WESTERLY HOSP RI
WESTERN PENNSYLVANIA HOSP
WESTSIDE REGIONAL MED CTR FL
WHEATON FRANCISCAN WI
WICKENBURG COMM HOSP AZ
WILKES BARRE BEHAV HOSP PA
WILLIAM BACKUS HOSPITAL CT
WILLIAM BEAUMONT HOSP
WILLIAMSPORT HOSPITAL PA
WINDBER HOSPITAL PA
WINDHAM COMMUNITY MEM HOSPITA
WING MEMORIAL HOSPITAL MA
WOMEN & INFANTS HSP RI
WOOD CTY HSP OH
WVHCS HOSP WILKES BARRE PA
WYTHE COUNTY COMM HOSP VA
YALE NEW HAVEN HOSPITAL CT
YAVAPAI REG MED CTR AZ
YORK HOSPITAL
YORK HOSPITAL ME
YOUNGSTOWN/NORTHSIDE MED OH
City, State
HONESDALE
WAYNESBORO
GOLDSBORO
WAYNESBORO
WEIRTON
AUSTELL
DOUGLASVILLE
MARIETTA
DALLAS
WEST ALLIS
WEST GROVE
MARRERO
VOORHEES TOWNSHIP
GOODYEAR
WESTBOROUGH
WESTERLY
PITTSBURGH
PLANTATION
MILWAUKEE
WICKENBURG
KINGSTON
NORWICH
ROYAL OAK
WILLIAMSPORT
WINDBER
WILLIMANTIC
PALMER
PROVIDENCE
BOWLING GREEN
WILKES BARRE
WYTHEVILLE
NEW HAVEN
PRESCOTT
YORK
YORK
YOUNGSTOWN
PA
TN
NC
PA
WV
GA
GA
GA
GA
WI
PA
LA
NJ
AZ
MA
RI
PA
FL
WI
AZ
PA
CT
MI
PA
PA
CT
MA
RI
OH
PA
VA
CT
AZ
PA
ME
OH
(1)
(2)
Rate Code 2953 (OOS Hospital DRG)
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 6,237.93
$ 5,599.08
$ 5,599.08
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
$ 5,599.08
$ 6,237.93
Rate Code 2952 (OOS Hospital Exempt)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
(3)
(4)
(5)
(6)
Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ 298.23
$ ‐
$ ‐
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
$ ‐
$ 298.23
Rate Codes 2950 and 2954 (ALC RHCF)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Codes 2951 and 2955 (ALC Home Care)
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
$ 171.74
Rate Code 2990 (Capital per Disch)
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
$ 488.62
21 of 21
(7)
(8)
(9)
Rate Code 2991 WEF/ISAF High Cost (Capital per (for High Cost Charge Convertors
Diem)
Claims)
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
$ 103.11
0.8424
0.449077
out_of_state_effective_04-01-12.xls