NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
ABBOTT NORTHWESTERN HSP MN
ADVENTIST MED CTR OR
AKRON GENERAL MEDICAL CENTER
ALAMANCE REG MED CTR NC
ALBERT EINSTEIN MED CTR PA
ALEGENT HLT BERGAN MERCY MED
ALEGENT HLTH IMMANUEL MED NE
ALEXIAN BROTHERS MEDICAL CENT
ALFRED I DUPONT HOSP FOR CHID
ALL CHILDRENS HOSPITAL FL
ALL SAINTS MEDICAL CENTER WI
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
ASPEN VALLEY HOSPITAL CO
ATHENS REG MED TN
ATLANTA MEDICAL CENTER GA
ATLANTIC GEN HSP MD
ATLANTICARE MEDICAL CTR
ATLANTICARE REG MED CTR CITY ATMORE COMM HSP AL
AUGUSTA MEDICAL CENTER VA
AURORA SINAI MED CTR WI
AVENTURA HOSP & MED CTR FL
AVERA MCKENNAN HOSP&UNIV HLTH
BALTIMORE WASHINGTON MEDICAL BANNER BAYWOOD MED CTR AZ
BANNER DEL E WEBB MEM HSP AZ
BANNER DESERT MED CTR AZ
BANNER ESTRELLA MED CTR AZ
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ ‐
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$ ‐
$ ‐
$ ‐
$ ‐
Rate Code 2589 (DME Add‐on)
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ ‐
$ ‐
$ ‐
$ 301.21
$ 301.21
$ ‐
$ ‐
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$ 301.21
$ ‐
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$ 301.21
$ ‐
$ ‐
$ 301.21
$ ‐
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$ 301.21
$ ‐
$ 301.21
$ ‐
$ ‐
$ ‐
$ ‐
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Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
1 of 26
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
BANNER GOOD SAMARITAN MED AZ
BANNER HEART HOSPITAL AZ
BANNER MESA MED CTR AZ
BANNER THUNDERBIRD MED CTR AZ
BAPTIST HOSPITAL FL
BAPTIST MEM HOSP DESOTO MS
BAPTIST MEM HOSP FOR WOMEN TN
BAPTIST MEM HOSP NORTH MS
BAPTIST MEM HOSP OF MEMPHIS
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 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
BEEBE MEDICAL CENTER DE
BERGEN PINES COUNTY HSP NJ
BERKSHIRE MEDICAL CTR MA INC
BERT FISH MEDICAL CENTER FL
BETH ISRAEL DEACONESS BOSTON BETHESDA HSP NORTH OH
BETHESDA MEMORIAL HOSPITAL FL
BETSY JOHNSON REG HOSP NC
BEVERLY HSP MA
BLAKE MEDICAL CENTER FL
BLOOMINGTON HSP IN
BLOOMSBURG HOSPITAL PA
BLUE RIDGE HOSP NC
BOCA RATON COMM HOSP FL
BOLIVAR MED CTR/PHC CLEVELAND
BON SECOURS DEPAUL MED CTR VA
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$
,
$ 7,138.18
$ 7,138.18
$ 6,270.42
$ 5,628.23
$ 8,593.66
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ ‐
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$ ‐
$ ‐
$ ‐
$ ‐
Rate Code 2589 (DME Add‐on)
$ 301.21
$ ‐
$ ‐
$ ‐
$ ‐
$ 301.21
$ 301.21
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ ‐
$ ‐
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$ 301.21
$ ‐
$ 301.21
$
$ ‐
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$ 301.21
$ ‐
$ 1,308.10
$ 301.21
$ ‐
$ 301.21
$ 301.21
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 301.21
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 263.81
$ 263.81
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
2 of 26
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 263.81
$ 263.81
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$
$ 674.25
$ 674.25
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$
$ 136.06
$ 136.06
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
1.0684
1.0684
0.8424
0.8424
1.0684
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.379209
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
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
BRIDGEPORT HOSPITAL
BRIGHAM AND WOMENS HOSP
BRISTOL HOSPITAL
BROADLAWNS MEDICAL CENTER IA
BROCKTON HOSP MA
BROMENN REG MED CTR IL
BRONSON METHODIST HOSP MI
BROOKEGLEN BEHAVIORAL HOSPITA
BROOKWOOD MED CTR AL
BROWARD GENERAL MEDICAL CTR
BRYANLGH MED CTR EAST NE
BRYN MAWR HOSPITAL PA
BRYN MAWR REHAB HOSP. PA
CAMBRIDGE MEDICAL CENTER MN
CAMDEN CLARK MEMORIAL HOSP WV
CANDLER HOSP GA
CAPE CANAVERAL HOSP FL
CAPE CORAL HSP FL
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 GOOD SAMARITAN MED CT
CARITAS NORWOOD HOSP MA
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 8,593.66
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$
,
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ ‐
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Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ 301.21
$ ‐
$ ‐
$ ‐
$ 1,308.10
$ 301.21
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$ 301.21
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$ 301.21
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$ 301.21
$ ‐
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$ 301.21
$ 301.21
$ ‐
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
1.0684
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
CAROLINAEAST HEALTH SYSTEM
CAROLINAS MEDICAL CENTER NC
CAROLINAS MEDICAL CENTER NORT
CAROLINAS MEDICAL CTR UNION N
CARONDELET ST JOSEPHS HSP AZ
CARONDELET ST MARYS HOSP AZ
CARROLL HOSPITAL CENTER MD
CASA GRANDE REG MED CTR AZ
CASTLE MEDICAL CENTER HI
CASTLEVIEW HOSPITAL UT
CATHOLIC HTHCRE WEST(ST ROSE)
CEDARS MEDICAL CENTER FL
CENTENNIAL HILLS HOSP MED CTR
CENTENNIAL MED CTR TN
CENTENNIAL MEDICAL CENTER TX
CENTRAL BAPTIST HOSPITAL KY
CENTRAL CAROLINA HOSPITAL NC
CENTRAL FLORIDA REG HOSP
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
CHARLOTTE HUNGERFORD HOSPITAL
CHARLOTTE REGIONAL MC FL
CHESAPEAKE GENERAL HOSP VA
CHESTER COUNTY HOSP PA
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
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
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$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$
,
$ 5,628.23
$ 5,628.23
$ 8,593.66
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 7,138.18
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
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$ ‐
Rate Code 2589 (DME Add‐on)
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ ‐
$ ‐
$ ‐
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$ ‐
$ ‐
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$ 301.21
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$ 1,308.10
$ 301.21
$ 301.21
$ ‐
$ 301.21
$ ‐
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Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
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$ 466.08
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$ 466.08
$ 466.08
$ 466.08
$ 466.08
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$ 466.08
$ 466.08
$
$ 466.08
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$ 466.08
$ 466.08
$ 466.08
$ 674.25
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$ 466.08
$ 466.08
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$ 466.08
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$ 466.08
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$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
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$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
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$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
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0.8424
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0.8424
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0.476642
0.476642
0.476642
0.476642
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0.476642
0.476642
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0.476642
0.476642
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0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
CHILDRENS HOSPITAL
CHILDRENS HOSPITAL CO
CHILDRENS HOSPITAL ALABAMA
CHILDRENS HOSPITAL CENTRAL CA
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
CHILDREN'S NATIONAL MED CTR
CHILDRENS SPECIALIZED HOSP NJ
CHILTON MEM HOSP NJ
CHIPPENHAM JOHNSTON WILLIS V
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
CLEVELAND CLINIC FOUNDATION
CLEVELAND CLINIC HOSPITAL FL
CMC PINEVILLE HOSPITAL NC
COATESVILLE HOSPITAL PA
COLLETON MEDICAL CENTER SC
COLUMBIA DOCTORS HSP FL
COLUMBIA HENRICO DOCTORS VA
COLUMBIA HSP FL
COLUMBIA WESLEY MEDICAL CENTE
COMMUNITY HLTH CTR BRANCH CTY
COMMUNITY HOSPITAL ASSOCIATIO
COMMUNITY HOSPITALS IN
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ ‐
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$ 8,593.66
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$
,
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
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$ 6,270.42
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$ 5,628.23
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$ 5,628.23
$ 6,270.42
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$ 6,270.42
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$ 6,270.42
$ ‐
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Rate Code 2589 (DME Add‐on)
$ ‐
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$ 301.21
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$ 301.21
$ 301.21
$ ‐
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$ 301.21
$ ‐
$ 301.21
$ ‐
$ 301.21
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
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$ 466.08
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$ 466.08
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$ 100.25
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$ 100.25
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$ 100.25
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0.8424
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0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
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0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
COMMUNITY HSP OF OTTAWA IL
COMMUNITY MED CTR NJ
COMMUNITY MEDICAL CENTER PA
COMMUNITY MEMORIAL HOSP VA
COMMUNITY REGIONAL MEDICAL CN
CONCORD HOSPITAL NH
CONEMAUGH VALLEY MEM HSP PA
CONNECTICUT CHILDRENS MED CTR
CONTRA COSTA REG MED CTR CA
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
COVENANT HEALTHCARE MI
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
CYPRESS FAIRBANKS M C TX
DANA FARBER CANCER INSTITUTE
DANBURY HOSP CT
DANVILLE REG MED CTR VA
DAVIS MEMORIAL HOSPITAL WV
DAY KIMBALL HOSPITAL CT
DEBORAH HEART AND LUNG CTR
DEL SOL MEDICAL CENTER TX
DELAWARE CTY MEMORIAL HSP PA
DELTA CTY MEM HSP CO
DESERT REG MED CTR CA
DESERT SPRINGS HOSP NV
DETROIT RECEIVING HSP MI
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
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$ 5,628.23
$ 5,628.23
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$ 6,270.42
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$ 6,270.42
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$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
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$ 5,628.23
$ 8,593.66
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
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$ 6,270.42
$ 5,628.23
$ 6,270.42
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Rate Code 2589 (DME Add‐on)
$ ‐
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$ ‐
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$ 301.21
$ 301.21
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$ ‐
$ ‐
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$ 301.21
$ ‐
$ 301.21
$ ‐
$ 301.21
$ ‐
$ 301.21
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
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$ 173.45
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$ 173.45
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$ 173.45
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$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
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$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
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$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
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0.8424
0.8424
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0.8424
0.8424
0.8424
0.8424
0.8424
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1.0684
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
DIXIE MEDICAL CENTER UT
DOCTORS COMMUNITY HOSPITAL MD
DOCTORS HOSP OF AUGUSTA GA
DOCTORS HOSPITAL TX
DOCTORS MEDICAL CNTR MODES CA
DOYLESTOWN HOSPITAL PA
DUBOIS REG MED CTR MERCY DIV
DUKE RALEIGH HOSPITAL NC
DUKE UNIVERSITY HOSPITAL NC
DURHAM REGIONAL HOSPITAL NC
EAST GEORGIA REG MED CTR
EAST JEFFERSON GEN HOSP LA
EAST ORANGE GENERAL HOSPITAL
EAST TENNESSE CHILD HOSP
EASTERN IDAHO REG MED CTR ID
EASTERN MAINE MED CTR ME
EASTERN NEW MEXICO MED NM
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 UNIVERSITY HSP GA
ENGLEWOOD COMM HOSP FL
ENGLEWOOD HOSP MED CTR NJ
EPHRATA COMMUNITY HOSPITAL PA
EXEMPLA LUTHERAN MED CTR CO
EXEMPLA ST JOSEPH HOSPITAL FAIRBANKS MEM HSP AK
FAIRFAX HOSPITAL VA
FAIRMONT GEN HSP WV
FAIRVIEW GENERAL HOSPITAL OH
FAIRVIEW HOSPITAL
FAIRVIEW NORTHLAND REG HSP MN
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 7,138.18
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$
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$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
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$ 6,270.42
$ 5,628.23
$ 8,593.66
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
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Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ ‐
$ ‐
$ 301.21
$ ‐
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ 301.21
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$ 301.21
$ 301.21
$ 301.21
$ 301.21
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$ 301.21
$ ‐
$ 1,308.10
$ ‐
$ ‐
$ 301.21
$ ‐
$ ‐
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$ 301.21
$ ‐
$ ‐
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
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$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
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$ 674.25
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$ 674.25
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$ 466.08
$ 466.08
$ 100.25
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$ 100.25
$ 100.25
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$ 100.25
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$ 136.06
$ 100.25
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$ 100.25
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$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
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0.8424
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0.8424
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0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
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0.8424
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0.8424
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0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
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0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
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0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
FAIRVIEW PARK HOSPITAL GA
FAIRVIEW UNIV MED CTR MN
FAWCETT MEMORIAL HOSPITAL FL
FAYETTE COUNTY HOSPITAL
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
FLOWER MEM HSP OH
FLOWERS HOSPITAL AL
FORT WASHINGTON HOSPITAL MD
FOUNDATIONS BEHAVIORAL HEALTH
FRANCISCAN HOSPITAL FOR CHILD
FRANKLIN REGIONAL MEDICAL CTR
FRANKLIN SQUARE HOSP MD
FROEDTERT MEM LUTHER WI
GARDEN CITY OSTEO HOSP MI
GASTON MEMORIAL HOSPITAL NC
GATEWAY MED CTR TN
GEARY COMMUNITY HSP KS
GEISINGER MEDICAL CENTER PA
GEISINGER SOUTH WILKES‐BARRE GEISINGER WYOMING VALLEY MED
GENESIS HEALTHCARE SYSTEM OH
GEORGETOWN MEMORIAL HOSP SC
GEORGETOWN UNIVERSITY HOSP DC
GERALD CHAMPION MEM HSP NM
GETTYSBURG HOSPITAL
GNADEN HUETTEN MEM HOSP PA
GOOD SAMARITAN HOSP OH
GOOD SAMARITAN HOSPITAL IN
GOOD SAMARITAN HOSPITAL MD
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 7,051.61
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
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$ 6,270.42
$ 6,270.42
$ 5,628.23
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$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
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$ 6,270.42
$ 5,628.23
$ 6,270.42
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$ 6,270.42
$ ‐
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Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
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$ 301.21
$ ‐
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$ 734.02
$ ‐
$ 301.21
$ ‐
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$ 301.21
$ 301.21
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$ 301.21
$ ‐
$ 301.21
$ ‐
$ 301.21
$ ‐
$ 301.21
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
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$ 100.25
$ 100.25
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$ 100.25
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$ 100.25
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$ 100.25
$ 100.25
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0.476642
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0.476642
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0.476642
0.476642
0.476642
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0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
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0.476642
0.476642
0.476642
0.476642
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0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
GOOD SAMARITAN HOSPITAL OH
GOOD SAMARITAN HOSPITAL WA
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
GRANT MEDICAL CENTER OH
GREATER BALTIMORE MED CTR MD
GREENE MEM HSP OH
GREENVIEW HOSPITAL KY
GREENVILLE MEM HSP SC
GREENWICH HOSP ASSOCIATION CT
GREER MEMORIAL HOSP SC
GRIFFIN HOSPITAL CT
GUNDERSEN LUTHERAN MED CTR WI
HACKENSACK UNIV MED CTR NJ
HACKETTSTOWN REG MED CTR
HACKLEY HOSPITAL MI
HAHNEMANN UNIV HSP PA
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
HARLINGEN MEDICAL CENTER
HARPER HUTZEL HOSPITAL MI
HARRINGTON MEMORIAL HOSPITAL HARRIS METHODIST HEB HOSP TX
HARTFORD HOSP CT
HAZLETON GEN HSP PA
HCA OAK HILL HOSP FL
HEALTH ALLIANCE HOSP
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
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$ 6,270.42
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$ 6,270.42
$ 8,593.66
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 8,593.66
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$ 6,270.42
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$ 5,628.23
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$ 6,270.42
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$ 5,628.23
$ 6,270.42
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Rate Code 2589 (DME Add‐on)
$ 301.21
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$ ‐
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$ 301.21
$ 301.21
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Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 263.81
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
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$ 173.45
$ 173.45
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$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 263.81
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$ 173.45
$ 173.45
$ 173.45
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$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 674.25
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$ 466.08
$ 466.08
$ 466.08
$ 466.08
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$ 466.08
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$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
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$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
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$ 136.06
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$ 100.25
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$ 100.25
$ 100.25
$ 100.25
$ 100.25
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$ 100.25
0.8424
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1.0684
0.8424
0.8424
0.8424
1.0684
0.8424
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0.8424
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0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
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0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
HEALTH PARK MEDICAL CENTER FL
HEALTHEAST WOODWINDS HOSPITAL
HEALTHSOUTH REHAB HOSP ERIE
HEART HOSPITAL BAYLOR PLANO T
HELEN ELLIS MEM HSP FL
HENRY CTY HSP OH
HENRY FORD HOSPITAL MI
HENRY FORD WYANDOTTE HOSPITAL
HENRY HEYWOOD MEM HOSP MA
HIALEAH HOSPITAL FL
HIGH POINT REG HEALTH SYS NC
HIGHLANDS HSP&HLTH CENTER
HIGHLINE MEDICAL CENTER WA
HILLCREST MEMORIAL HOSP SC
HINSDALE HOSPITAL
HOLMES REG MED CTR FL
HOLSTON VALLEY MEDICAL CENTER
HOLY CROSS HOSPITAL NM
HOLY CROSS HSP FL
HOLY FAMILY HOSP INC MA
HOLY NAME HOSPITAL NJ
HOLY REDEEMER HOSPITAL PA
HOLY SPIRIT HOSPITAL
HOLYOKE HOSP MA
HORIZON HSP SYSTMS PA
HOSPITAL OF ST RAPHAEL CT
HOSPITAL OF THE UNIV OF PENN
HOWARD COUNTY GENERAL HOSP 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
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$
$ 5,628.23
,
$ 7,138.18
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
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Rate Code 2589 (DME Add‐on)
$ ‐
$ 301.21
$ ‐
$ 301.21
$ ‐
$ ‐
$ 301.21
$ 301.21
$ ‐
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$ 301.21
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$ 301.21
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$ 301.21
$ 301.21
$ 301.21
$ ‐
$ ‐
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$ ‐
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
0.8424
0.8424
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0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
1.0684
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
INGHAM REGIONAL MEDICAL CENTE
INTEGRIS BAPTIST MED CTR OK
INTERMOUNTAIN MEDICAL CENTER IOWA METHODIST MED CTR IA
IREDELL MEMORIAL HOSPITAL NC
IRVINE MEDICAL CENTER CA
JACKSON COUNTY MEM OK
JACKSON MADISON CTY GEN TN
JACKSON MEM HSP FL
JAMES LAWRENCE KERNAN HOSPITA
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 HSP THE OH
JOHN C LINCOLN DEERVALLEY AZ
JOHN C LINCOLN HOSP HLTH AZ
JOHN DEMPSEY HOSPITAL UNIV CT
JOHN F KENNEDY MED CTR
JOHN RANDOLPH MEDICAL CTR VA
JOHNS HOPKINS BAYVIEW MED MD
JOHNS HOPKINS HOSPITAL MD
JOHNSON CITY MED CTR TN
JOHNSON MEM HSP
KENDALL REG MED CTR FL
KENNEDY KRIEGER INSTITUTE MD
KENNEDY MEM HOSP/UMC STRATFOR
KENT COUNTY MEMORIAL HOSPITAL
KERN MEDICAL CTR CA
KERSHAW CTY MED CTR SC
KESSLER INSTITUTE FOR REHAB I
KETTERING MED CTR OH
KIMBALL MEDICAL CENTER
KINGMAN REGIONAL MED CTR AZ
KOOTENAI MEDICAL CENTER ID
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 7,138.18
$ 8,593.66
$ 6,270.42
$ 6,270.42
$
,
$ 5,628.23
$ 6,270.42
$ 8,593.66
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 7,138.18
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ ‐
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$ ‐
$ ‐
Rate Code 2589 (DME Add‐on)
$ 301.21
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ ‐
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ 301.21
$ ‐
$ 301.21
$ ‐
$ ‐
$ 1,308.10
$ 301.21
$ 301.21
$
$ ‐
$ 301.21
$ 1,308.10
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ 301.21
$ ‐
$ 301.21
$ ‐
$ 301.21
$ ‐
$ ‐
$ 301.21
$ ‐
$ 301.21
$ ‐
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 263.81
$ 173.45
$ 173.45
$
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
11 of 26
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 263.81
$ 173.45
$ 173.45
$
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 674.25
$ 466.08
$ 466.08
$
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 136.06
$ 100.25
$ 100.25
$
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
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0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
1.0684
1.0684
0.8424
0.8424
0.8424
0.8424
1.0684
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
1.0684
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.379209
0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
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
LANDMARK MEDICAL CENTER RI
LARGO MEDICAL CENTER FL
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 MERIDIAN PARK HSP OR
LEGACY MOUNT HOOD MED CTR OR
LEHIGH VALLEY HOSP CTR PA
LEHIGH VALLEY MUHLENBERG PA
LENOIR MEMORIAL HOSPITAL NC
LESTER E COX MEDICAL CENTER
LEWIS‐GALE MEDICAL CTR VA
LEXINGTON MEDICAL CENTER SC
LIBERTY HOSPITAL MO
LITTLE COLORADO MED CTR
LODI MEM HSP CA
LOMA LINDA UNIV MED CENTER CA
LONG BEACH MEM MED CTR CA
LONGMONT UNITED HOSPITAL CO
LORIS COMMUNITY HOSPITAL SC
LOS ANGELES COUNTY MED CTR CA
LOUDOUN HOSPITAL CENTER VA
LOUIS A WEISS MEMORIAL HOSP I
LOURDES MED CTR BURLINGTON CT
LOWELL GENERAL HOSPITAL MA
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$
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$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ ‐
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Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 301.21
$ ‐
$ ‐
$ ‐
$ 301.21
$ 301.21
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$ 301.21
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$ 301.21
$ ‐
$ ‐
$ 301.21
$ ‐
$ ‐
$ 301.21
$ ‐
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
12 of 26
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
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$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
0.8424
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0.8424
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0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
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0.8424
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0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
LUCILE SALTER PACKARD CHLD
LUTHER HSP WI
LUTHERAN MEDICAL CENTER OH
LUTHERN GEN HOSPITAL
LYNCHBURG GENERAL HOSP VA
MACNEAL HOSPITAL IL
MAGEE REHAB HOSPITAL‐PA
MAIN LINE HSP LANKENAU PA
MAINE GEN MED CTR ME
MAINE MED CTR ME
MANATEE MEMORIAL HSP FL
MARCUS J LAWRENCE MEM HOSP AZ
MARIA PARHAM HOSPITAL NC
MARIAN COMMUNITY HOSPITAL PA
MARICOPA MEDICAL CENTER AZ
MARLBOROUGH HOSP MA
MARTHAS VINEYARD HOSPITAL MA
MARY HITCHCOCK MEM HOSP NH
MARY IMMACULATE HOSPITAL VA
MARY WASHINGTON HOSPITAL VA
MARYLAND GEN HSP MD
MARYMOUNT HOSPITAL OH
MARYVIEW MEDICAL CENTER VA
MASS EYE AND EAR INFIRMARY
MASSACHUSETTS GEN HOSP
MAYO CLINIC ARIZONA
MAYO CLINIC FLORIDA
MCKEE MED CTR CO
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 MC KINNEY T
MEDICAL CTR CENTRAL GEORGIA G
MEDICAL CTR OF ARLINGTON TX
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
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$ 5,628.23
$ 6,270.42
$ 7,138.18
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$ 6,270.42
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$ 5,628.23
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Rate Code 2589 (DME Add‐on)
$ ‐
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$ 301.21
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Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
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$ 173.45
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$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 466.08
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$ 100.25
$ 100.25
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$ 136.06
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$ 100.25
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$ 100.25
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0.476642
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0.476642
0.476642
0.476642
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0.476642
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0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
MEDICAL CTR OF AURORA CO
MEDICAL CTR OF OCEAN CO.
MEDICAL UNIVERSITY HSP OF SC
MEDINA GEN HSP OH
MELROSE WAKEFIELD HSP MA
MEMORIAL HERMANN KATY HOSPITA
MEMORIAL HERMANN SE & SW HOSP
MEMORIAL HLTH UNIV MED CTR GA
MEMORIAL HOSP MED CTR MD
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 WEST FL
MEMORIAL HSP CO
MEMORIAL HSP OF EASTON MD INC
MEMORIAL MED CTR IL
MEMORIAL MEDICAL CENTER IL
MEMORIAL REG HSP FL
MENDOTA COMMUNITY HOSP IL
MERCY FITZGERALD HOSPITAL PA
MERCY HOSP OF PHILADELPHIA
MERCY HOSP/MERCY HOSP SOUTH N
MERCY HOSPITAL PA
MERCY HSP GRAYLING MI
MERCY HSP MN
MERCY HSP TIFFIN OH
MERCY HSP WILLARD OH
MERCY MED CTR N IOWA
MERCY MED CTR SIOUX CITY IA
MERCY MED CTR WI
MERCY MEDICAL CENTER MA
MERCY MEDICAL CENTER MD
MERCY MEDICAL CENTER OR
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
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Rate Code 2589 (DME Add‐on)
$ 301.21
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$ 301.21
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Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
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$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
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0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
MERCY MEMORIAL HOSPITAL MI
MERCY SUBURBAN HSP PA
MERIDIA EUCLID HSP OH
MERIDIA HILLCREST HSP OH
MERIDIA HURON HSP OH
MERIT MOUNTAINSIDE HOSP NJ
MERITCARE HSP ND
MERRIMACK VALLEY HSP MA
MESA GEN HSP AZ
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 HOSP CT
MIDDLETOWN REGIONAL HOSPITAL MIDSTATE MEDICAL CENTER CT
MIDWEST CITY REGIONAL HOSP OK
MILES MEMORIAL HOSPITAL ME
MILFORD HOSPITAL CT
MILLCREEK COMMUNITY HOSPITAL
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
MORRISTOWN MEMORIAL HOSP NJ
MORTON PLANT HOSP FL
$ 5,628.23
$ 6,270.42
$ 5,628.23
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$ 8,593.66
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Rate Code 2589 (DME Add‐on)
$ ‐
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$ 301.21
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
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$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 263.81
$ 173.45
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$ 263.81
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
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$ 466.08
$ 466.08
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$ 100.25
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$ 136.06
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0.476642
0.476642
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0.379209
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0.379209
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0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
MOSES H CONE HOSPITAL NC
MOSES TAYLOR HOSPITAL
MOUNT CARMEL EAST OH
MOUNT SINAI MEDICAL CTR OF FL
MOUNTAINSIDE HOSP NJ
MT ASCUTNEY HOSP AND HLTH CTR
MT CARMEL WEST HOSPITAL OH
MT GRAHAM REG MED CTR AZ
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
NATCHEZ REGIONAL MED CNTR MS
NATIONAL HSP KIDS IN CRISIS P
NAZARETH HOSPITAL PA
NEBRASKA MEDICAL CENTER NE
NEW ENGLAND SINAI HSP MA
NEW MILFORD HSP
NEWARK BETH ISRAEL MED CTR NJ
NEWPORT HSP RI
NEWTON MEMORIAL HOSPITAL NJ
NEWTON WELLESLEY HOSP MA
NOBLE HOSPITAL 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 HILLS HOSPITAL TX
NORTH PHILADELPHIA HLTH SYS
NORTH SHORE MED CTR FL
NORTH SHORE MED CTR FMC FL
NORTH SUBURBAN MED CTR CO
NORTH VISTA HOSPITAL NV
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 8,593.66
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$
,
$ 5,628.23
$ 7,138.18
$ 8,593.66
$ 5,628.23
$ 7,138.18
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ ‐
$ ‐
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$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
Rate Code 2589 (DME Add‐on)
$ 301.21
$ 301.21
$ 301.21
$ 301.21
$ 1,308.10
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
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$ 301.21
$
$ ‐
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$ 1,308.10
$ ‐
$ ‐
$ 301.21
$ ‐
$ ‐
$ ‐
$ ‐
$ 301.21
$ 301.21
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 263.81
$ 263.81
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
16 of 26
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 263.81
$ 263.81
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$
$ 466.08
$ 674.25
$ 674.25
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$
$ 100.25
$ 136.06
$ 136.06
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
0.8424
0.8424
0.8424
0.8424
1.0684
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
1.0684
1.0684
0.8424
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0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.379209
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
NORTHCREST MEDICAL CENTER
NORTHEAST ALABAMA REG MED
NORTHEAST BAPTIST HOSP TX
NORTHERN COCHISE COMM HSP AZ
NORTHERN HOSP OF SURRY CO NC
NORTHSHORE REGIONAL MED LA
NORTHSHORE UNIVERSITY HEALTH NORTHSIDE HOSP FL
NORTHWEST HOSPITAL CENTER MD
NORTHWEST MED CTR AZ
NORTHWEST TEXAS HOSPITAL
NORTHWESTERN MEDICAL CTR VT
NORTON HOSPITAL KY
NORWALK HOSPITAL
OAK VALLEY HOSPITAL DISTRICT OAKWOOD HOSP HERITAGE CTR MI
OAKWOOD HOSPITAL MI
OCHSNER CLINIC FOUND HOSP LA
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
OUR LADY OF THE LAKE RMC LA
OUTER BANKS HSP THE NC
OVERLOOK HOSPITAL NJ
PALISADES MEDICAL CENTER NJ
PALM BEACH GARDENS AND MED CT
PALMERTON HOSPITAL PA
PALMETTO GENERAL HOSPITAL FL
PALMETTO HEALTH ALLIANCE SC
PALMS OF PASADENA HSP FL
PALMYRA PARK HSP GA
PAOLI MEMORIAL HOSPITAL
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 8,593.66
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$
$ 6,270.42
,
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 8,593.66
$ 7,138.18
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ ‐
$ ‐
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$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
Rate Code 2589 (DME Add‐on)
$ ‐
$ 301.21
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 301.21
$ ‐
$ ‐
$ 301.21
$ ‐
$ 301.21
$ 1,308.10
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ 301.21
$
$ 301.21
$ 301.21
$ ‐
$ ‐
$ 301.21
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ 1,308.10
$ ‐
$ ‐
$ ‐
$ 301.21
$ 301.21
$ ‐
$ ‐
$ ‐
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
17 of 26
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
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0.8424
0.8424
0.8424
0.8424
1.0684
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
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0.8424
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1.0684
1.0684
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
PARKER ADVENTIST HEALTH CO
PARKLAND MEM HOSP TX
PARKVIEW HSP ME
PARKVIEW MED CTR CO
PARKWEST MEDICAL CENTER TN
PARRISH MED CTR FL
PEACE RIVER REGIONAL MEDICAL PENINSULA REGIONAL MEDICAL CT
PENNSYLVANIA HOSP PA
PENOBSCOT BAY MED CTR ME
PERSON COUNTY MEM HOSP NC
PETERSON REGIONAL MEDICAL CEN
PHOENIX BAPTIST HOSP AZ
PHOENIX CHILDRENS HSP AZ
PHYSICIANS REGIONAL MEDICAL C
PIEDMONT MED CTR SC
PINNACLE HEALTH HOSPITALS PA
PIONEER VALLEY HOSPITAL UT
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
PORTNEUF MEDICAL CENTER ID
POTOMAC VALLEY HSP OF WEST VA
POTTSTOWN MEM MED CTR PA
POUDRE VALLEY HSP CO
PRESBYTERIAN HOSP NM
PRESBYTERIAN HSP OF DALLAS
PRESBYTERIAN ST LUKES MED CO
PRESTON MEMORIAL HOSP WV
PRINCE GEORGES HOSP CTR MD
PRINCETON COMMUNITY HOSP WV
PROVIDENCE HOSP&MED CTR MI PROVIDENCE HOSPITAL MA
PROVIDENCE MED CTR KS
PROVIDENCE MEMORIAL HOSPITAL $ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$
$ 5,628.23
,
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ ‐
$ ‐
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$ ‐
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$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
Rate Code 2589 (DME Add‐on)
$ ‐
$ 301.21
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ ‐
$ 301.21
$ ‐
$ 301.21
$ ‐
$ 301.21
$ ‐
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$ ‐
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$
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$ 301.21
$ ‐
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$ 301.21
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ 301.21
$ ‐
$ 301.21
$ ‐
$ ‐
$ 301.21
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
18 of 26
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
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
REG CTR ORANGEBURG CALHOUN SC
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
RIVERVIEW HOSPITAL NJ
ROANOKE CHOWAN HOSPITAL NC
ROBERT PACKER HOSP PA
ROBERT W JOHNSON UNIV HSP RAH
ROBERT WOOD JOHNSON UNIV HSP
ROCKFORD MEMORIAL HOSPITAL IL
ROCKINGHAM MEMORIAL HSP VA
ROGER WILLIAMS GENERAL HOSP
ROGUE VALLEY MEMORIAL HSP OR
ROLLINS BROOK COMMUNITY HOSPI
ROUND ROCK HOSPITAL TX
ROXBOROUGH MEMORIAL HOSPITAL $ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 7,138.18
$ 6,270.42
$ 8,593.66
$ 6,270.42
$ 5,628.23
$ 5,628.23
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$ 6,270.42
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$ 5,628.23
$ 6,270.42
$ 7,138.18
$ 8,593.66
$ 5,628.23
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$ 6,270.42
$ 5,628.23
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$ 5,628.23
$ 6,270.42
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Rate Code 2589 (DME Add‐on)
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ 301.21
$ ‐
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$ 301.21
$ 1,308.10
$ 301.21
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Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
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$ 173.45
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$ 263.81
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$ 173.45
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$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 263.81
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
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$ 674.25
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NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
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 MEM MED CTR MA
SALINA REG HLTH CTR KS
SAMPSON REGIONAL MEDICAL CENT
SAN ANTONIO COMM HSP CA
SAN JOAQUIN COMMUNITY HOSPITA
SAN RAMON MEDICAL CTR CA
SANTA ROSA HOSPITAL TX
SARASOTA MEMORIAL HOSPITAL FL
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 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
SEWICKLEY VALLEY HOSPITAL PA
SHANDS TEACHING HOSPITAL FL
SHARON HOSPITAL CT
SHARP CHULA VISTA
SHARP MEM HSP CA
SHELBY CTY/WILSON MEMORIAL OH
SHORE MEMORIAL HOSPITAL
SILVER CROSS HOSPITAL IL
SINAI‐GRACE HOSPITAL MI
SKAGGS COMM HEALTH MO
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
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$ 6,270.42
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$ 6,270.42
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$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 7,138.18
$ 5,628.23
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Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 263.81
$ 173.45
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$ 173.45
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$ 263.81
$ 173.45
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$ 173.45
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$ 173.45
$ 466.08
$ 466.08
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0.476642
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0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
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 POINTE HOSPITAL OH
SOUTH SHORE HOSP MA
SOUTHCREST HSP OK
SOUTHEASTERN OHIO REG MED CTR
SOUTHEASTERN REG MED CTR NC
SOUTHERN HILLS HOSPITAL NV
SOUTHERN HILLS M C TN
SOUTHERN MAINE MEDICAL CENTER
SOUTHERN MARYLAND HOSP INC
SOUTHERN NEW HAMPSHIRE REG MC
SOUTHERN OCEAN COUNTY HOSP NJ
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
SPRING VALLEY HSP NV
SPRINGFIELD KINDRED PARKVIEW
SSM ST MARYS HLTH CTR MO
ST ALPHONSUS REG MED CTR ID
ST ANNES HSP MA
ST ANTHONY CENTRAL HOSPITAL C
ST ANTHONY SUMMIT HOSPITAL CO
ST CATHERINE HSP IN
ST CHRISTOPHERS HSP CHILD PA
ST CLARES HOSPITAL
ST CLOUD HOSPITAL
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
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Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
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$ 173.45
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$ 173.45
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$ 173.45
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$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
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$ 466.08
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$ 466.08
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$ 466.08
$ 100.25
$ 100.25
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0.476642
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0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
ST DOMINIC JACKSON MEM HOSP
ST ELIZABETH HEALTH CENTER OH
ST ELIZABETH HOSPITAL IN
ST ELIZABETH HSP WI
ST ELIZABETH MED CTR KY
ST FRANCIS HOSP & MED CTR CT
ST FRANCIS HOSPITAL OK
ST FRANCIS HSP DE
ST FRANCIS MEDICAL CENTER
ST FRANCIS MEDICAL CENTER NE
ST JAMES HLTH CAREHSP MT
ST JOHN HOSPITAL KS
ST JOHNS HOSP IL
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 FL
ST JOSEPHS HOSPITAL GA
ST JOSEPHS REG MED CTR IN
ST JOSEPHS WAYNE GEN HSP
ST JUDE CHILDRENS RES HSP TN
ST LOUIS CHILDRENS HOSP MO
ST LUKES COMM MC WOODLANDS TX
ST LUKES HOSP WEST KY
ST LUKES HOSPITAL
ST LUKES HOSPITAL
ST LUKES HOSPITAL OH
ST LUKES HSP OF KC MO
ST LUKES MED CTR AZ
ST LUKES NORTHLAND HSP MO
ST MARGARET MERCY HLTH IN
ST MARKS HOSPITAL UT
ST MARY HOSPITAL PA
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
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$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$
,
$ 5,628.23
$ 8,593.66
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 7,138.18
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ ‐
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Rate Code 2589 (DME Add‐on)
$ ‐
$ 301.21
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ ‐
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$ 301.21
$ 301.21
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$ 301.21
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$ 301.21
$
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$ 1,308.10
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$ 301.21
$ ‐
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$ 301.21
$ 301.21
$ ‐
$ 301.21
$ 301.21
$ ‐
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$ 301.21
$ 301.21
$ ‐
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
22 of 26
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$
$ 466.08
$ 674.25
$ 466.08
$ 466.08
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$ 674.25
$ 466.08
$ 466.08
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$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
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$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
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$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
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0.8424
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0.8424
0.8424
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0.8424
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0.8424
0.8424
0.8424
0.8424
0.8424
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0.8424
0.8424
0.8424
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1.0684
0.8424
0.8424
0.8424
1.0684
0.8424
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0.476642
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0.476642
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0.476642
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0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
ST MARY HSP HOBOKEN NJ
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 IN
ST MARYS MEDICAL CENTER FL
ST MICHAEL MED CENTER NJ
ST PETERS UNIV HSP NJ
ST PETERSBURG GEN HSP FL
ST ROSE HOSPITAL CA
ST THOMAS MORE HOSPITAL CO
ST VINCENT CHARITY HOSPITAL O
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
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 EAST PA
TEMPLE LOWER BUCKS HSP PA
TEMPLE UNIVERSITY HOSPITAL
TEXAS CHILDREN'S HOSP TX
$ 7,138.18
$ 5,628.23
$ 5,628.23
$ 7,138.18
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 7,138.18
$ 7,138.18
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 8,593.66
$ 5,628.23
$ 8,593.66
$
,
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ ‐
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Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
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$ 301.21
$ ‐
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$ 301.21
$ 301.21
$ 1,308.10
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$ ‐
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$ 301.21
$ ‐
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$ 301.21
$ ‐
$ 301.21
$ ‐
$ ‐
$ 301.21
$ ‐
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 263.81
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 263.81
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
23 of 26
$ 263.81
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 263.81
$
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 674.25
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 674.25
$ 466.08
$ 466.08
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$ 466.08
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$ 674.25
$ 466.08
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$ 466.08
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$ 466.08
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$ 136.06
$ 100.25
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$ 136.06
$ 100.25
$ 100.25
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$ 100.25
$ 136.06
$ 136.06
$ 100.25
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$ 100.25
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$ 136.06
$ 100.25
$ 136.06
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$ 100.25
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$ 100.25
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$ 100.25
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$ 100.25
$ 100.25
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$ 100.25
$ 100.25
$ 100.25
1.0684
0.8424
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0.8424
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0.8424
0.8424
1.0684
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0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
1.0684
0.8424
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0.8424
0.8424
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0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.379209
0.379209
0.476642
0.476642
0.476642
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0.476642
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0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
THOMAS JEFFERSON UNIV HOSP PA
THREE RIVERS COMMUNITY HSP OR
TOLEDO HSP OH
TOWN & COUNTRY HSP FL
TRIDENT MEDICAL CENTER SC
TRINITAS HSP NJ
TROY COMMUNITY HOSPITAL
TRUMBULL MEM HOSP OH
TUCSON MED CTR AZ
TUFTS MEDICAL CENTER MA
TUOMEY REG MED CTR SC
TYLER MEMORIAL HOSPITAL PA
UCLA MEDICAL CENTER CA
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 REG HEALTHCARE SYS TX
UNITY HSP MN
UNIV CA DAVIS MED CTR CA
UNIV KENTUCKY HOSPITAL
UNIV MED CTR SO NEVADA
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 WICSONSIN HSP & CLINICS
UNIVERSITY COMM HOSP FL
UNIVERSITY HOSPITAL NC
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 8,593.66
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$
,
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 8,593.66
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ ‐
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Rate Code 2589 (DME Add‐on)
$ 301.21
$ ‐
$ 301.21
$ ‐
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$ 1,308.10
$ ‐
$ ‐
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$ 301.21
$ ‐
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$ 301.21
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$ 301.21
$ 301.21
$ 1,308.10
$ 301.21
$ 301.21
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ ‐
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
24 of 26
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
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$ 173.45
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$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
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$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
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$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
0.8424
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1.0684
0.8424
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0.8424
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0.8424
1.0684
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
UNIVERSITY HOSPITAL CO
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
UPMC MERCY HOSPITAL PA
UPPER CHESAPEAK MEDICAL CENTE
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
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 CTR DC
WASHINGTON HOSPITAL PA
WATERBURY HOSPITAL CT
WAUKESHA MEMORIAL HOSPITAL WI
WAYNE MEMORIAL HOSP PA
WAYNE MEDICAL CENTER TN
WAYNE MEM HSP NC
WAYNESBORO HSP PA
WELLSTAR COBB HOSP GA
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 7,138.18
$ 6,270.42
$
$ 5,628.23
,
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ ‐
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Rate Code 2589 (DME Add‐on)
$ ‐
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ 301.21
$ 301.21
$ ‐
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$ 301.21
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$ 301.21
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$ 301.21
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$ 301.21
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$ 301.21
$ 301.21
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$ 301.21
$ ‐
$ 301.21
$ 301.21
$ 301.21
$ 301.21
$ ‐
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Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
25 of 26
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 263.81
$ 173.45
$
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 674.25
$ 466.08
$
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 136.06
$ 100.25
$
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
0.8424
0.8424
0.8424
0.8424
0.8424
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0.8424
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0.8424
0.8424
0.8424
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0.8424
1.0684
0.8424
0.8424
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0.8424
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0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.379209
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
NEW YORK STATE DEPARTMENT OF HEALTH
OFFICE OF HEALTH INSURANCE PROGRAMS
SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 01/01/11 ‐ 03/31/11
Hospital Name
Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG)
Exempt)
WENTWORTH DOUGLASS HOSP NH
WEST ALLIS MEMORIAL HOSP WI
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
WHIDBEY GENERAL HOSPITAL WA
WILLIAM BACKUS HOSPITAL CT
WILLIAM BEAUMONT HOSP
WILLIAMSPORT HOSPITAL PA
WINDBER HOSPITAL PA
WINDHAM COMMUNITY MEM HOSPITA
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
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 6,270.42
$ 5,628.23
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ 6,270.42
$ 5,628.23
$ $
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,
$ 5,628.23
$ 6,270.42
$ ‐
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‐
$ ‐
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Rate Code 2589 (DME Add‐on)
$ ‐
$ 301.21
$ 301.21
$ ‐
$ ‐
$ ‐
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$ 301.21
$ ‐
$ ‐
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$ 301.21
$ 301.21
$ ‐
$ ‐
$ 301.21
$ ‐
$ 301.21
$ ‐
$
$ 301.21
$ ‐
$ 301.21
Rate Code Rate Code 2951 and 2955 Rate Code 2991 WEF/ISAF High Cost 2950 and 2954 (ALC Home Rate Code 2990 (Capital per (for High Cost Charge Convertors
(ALC RHCF)
Care)
(Capital per Disch)
Diem)
Claims)
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 173.45
$ 173.45
26 of 26
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$ 173.45
$
$ 173.45
$ 173.45
$ 173.45
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$ 466.08
$
$ 466.08
$ 466.08
$ 466.08
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$ 100.25
$
$ 100.25
$ 100.25
$ 100.25
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.8424
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642
0.476642