NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name ABBOTT NORTHWESTERN HSP MN ACADIA HOSPITAL ME ACUTE CARE SPECIALTY OH ADVENTIST MED CTR OR AKRON GENERAL MEDICAL CENTER ALAMANCE REG MED CTR NC ALBERT EINSTEIN MED CTR PA ALEGENT 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 ARROWHEAD REG HSP CA 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 BANNER GATEWAY MC AZ BANNER GOOD SAMARITAN MED AZ BANNER HEART HOSPITAL AZ BANNER IRONWOOD MED CTR AZ BANNER MESA MED CTR AZ City, State MINNEAPOLIS BANGOR CANTON PORTLAND AKRON BURLINGTON PHILADELPHIA OMAHA OMAHA ELK GROVE VILLAGE WILMINGTON ST PETERSBURG RACINE PITTSBURGH PITTSBURGH JACKSON NATRONA HEIGHTS GLENDALE GRAND FORKS BERLIN LANCASTER PHILADELPHIA LITTLE ROCK PRESQUE ISLE COLTON ASPEN ATHENS ATLANTA BERLIN LYNN ATLANTIC CITY ATMORE FISHERSVILLE MILWAUKEE AVENTURA SIOUX FALLS GLEN BURNIE MESA SUN CITY MESA PHOENIX GILBERT PHOENIX MESA SAN TAN VALLEY MESA Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) MN ME OH OR OH NC PA NE NE IL DE FL WI PA PA MI PA AZ ND NH CA PA AR ME CA CO TN GA MD MA NJ AL VA WI FL SD MD AZ AZ AZ AZ AZ AZ AZ AZ AZ $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ 1 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 0.8424 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 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name BANNER THUNDERBIRD MED CTR AZ BAPTIST HOSPITAL FL BAPTIST HOSPITAL OF MIAMI FL BAPTIST MEM HOSP DESOTO MS BAPTIST MEM HOSP NORTH MS BAPTIST MEM HOSP OF MEMPHIS BAPTIST ST ANTHONYS MEM HOSP BARBERTON CITIZENS HOSP OH BARNES JEWISH HSP MO BARNES‐KASSON COUNTY HSP BARTON MEMORIAL HOSPITAL CA BAY MEDICAL CTR FL BAYHEALTH KENT GEN HSP DE BAYLOR ALL SAINTS MED CTR TX BAYLOR MED CTR GARLAND TX BAYLOR MED CTR GRAPE VINE TX BAYLOR UNIVERSITY MED CTR TX BAYONNE MEDICAL CENTER NJ BAYSHORE COMMUNITY HOSPITAL BAYSTATE MEDICAL CENTER MA BEEBE MEDICAL CENTER DE BERGEN PINES COUNTY HSP NJ BERKSHIRE MEDICAL CTR MA INC BERT FISH MEDICAL CENTER FL BERTIE MEMORIAL HSP NC 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 BLUEFIELD HOSPITAL CO WV BOCA RATON COMM HOSP FL BOLIVAR MED CTR/PHC CLEVELAND BON SECOURS DEPAUL MED CTR VA BON SECOURS MEM REG VA BON SECOURS RICHMOND COMM VA BORGESS MEDICAL CENTER MI BOSTON MEDICAL CENTER MA BOTSFORD HOSPITAL MI BOZEMAN DEACONESS HOSP MT BRACKENRIDGE HSP TX BRADFORD REGIONAL MED CTR PA Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State GLENDALE PENSACOLA MIAMI SOUTHAVEN OXFORD MEMPHIS AMARILLO BARBERTON SAINT LOUIS SUSQUEHANNA SOUTH LAKE TAHOE PANAMA CITY DOVER FORT WORTH GARLAND GRAPEVINE DALLAS BAYONNE HOLMDEL SPRINGFIELD LEWES PARAMUS PITTSFIELD NEW SMYRNA BEACH WINDSOR BOSTON CINCINNATI BOYNTON BEACH DUNN BEVERLY BRADENTON BLOOMINGTON BLOOMSBURG SPRUCE PINE BLUEFIELD BOCA RATON CLEVELAND NORFOLK MECHANICSVILLE RICHMOND KALAMAZOO BOSTON FARMINGTON HILLS BOZEMAN AUSTIN BRADFORD AZ FL FL MS MS TN TX OH MO PA CA FL DE TX TX TX TX NJ NJ MA DE NJ MA FL NC MA OH FL NC MA FL IN PA NC WV FL MS VA VA VA MI MA MI MT TX PA $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 7,067.51 $ 7,067.51 $ 6,208.33 $ 5,572.51 $ 8,508.57 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 1,295.15 $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ 2 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 261.20 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 261.20 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 $ 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 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 0.8424 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 0.379209 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 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name BRANDON HOSPITAL FL BRATTLEBORO MEM HOSPITAL VT BRATTLEBORO RETREAT HSP 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 FEAR VALLEY NC CAPE REGIONAL MEDICAL CENTER CAPITAL HEALTH SYS AT FULD CAPITAL HEALTH SYSTEM MERCER CARILION FRANKLIN MEMORIAL VA CARILION ROANOKE COMM HSP VA CARILION ROANOKE MEMORIAL CARILION STONEWALL JACKSN VA CARITAS CARNE HSP MA CARITAS GOOD SAMARITAN MED CT CARITAS NORWOOD HOSP MA 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) CATHOLIC MED CTR NH CEDARS MEDICAL CENTER FL CENTENNIAL HILLS HOSP MED CTR Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State BRANDON BRATTLEBORO BRATTLEBORO BRIDGEPORT BOSTON BRISTOL DES MOINES BROCKTON NORMAL KALAMAZOO FORT WASHINGTON BIRMINGHAM FT LAUDERDALE LINCOLN BRYN MAWR MALVERN CAMBRIDGE PARKERSBURG SAVANNAH COCOA BEACH CAPE CORAL FAYETTEVILLE CAPE MAY COURT HOUSE TRENTON TRENTON ROCKY MOUNT ROANOKE ROANOKE LEXINGTON DORCHESTER CENTER BROCKTON NORWOOD NEW BERN CHARLOTTE CONCORD MONROE TUCSON TUCSON WESTMINSTER CASA GRANDE KAILUA PRICE LAS VEGAS MANCHESTER MIAMI LAS VEGAS FL VT VT CT MA CT IA MA IL MI PA AL FL NE PA PA MN WV GA FL FL NC NJ NJ NJ VA VA VA VA MA MA MA NC NC NC NC AZ AZ MD AZ HI UT NV NH FL NV $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 8,508.57 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ ‐ $ ‐ $ 1,295.15 $ 298.23 $ ‐ $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ 3 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 $ 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 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 0.8424 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 0.379209 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 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 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name 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 CHESHIRE MEDICAL CTR NH 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 CHILDRENS HOSPITAL CHILDRENS HOSPITAL CO CHILDRENS HOSPITAL ALABAMA CHILDRENS HOSPITAL CENTRAL CA CHILDRENS HOSPITAL OF PITTS CHILDRENS HOSPITAL OF PITTS CHILDRENS HOSPITAL OH CHILDRENS HSP KINGS DAUGHTER CHILDRENS HSP REG MED CTR WA CHILDRENS INSTITUTE OF PITTS CHILDRENS MEDICAL CENTER OH CHILDRENS MEM HSP IL CHILDRENS MERCY HOSPITAL MO CHILDRENS NATIONAL MED CTR CHILDRENS SPECIALIZED HOSP NJ CHILTON MEM HOSP NJ CHIPPENHAM JOHNSTON WILLIS V CHOWAN HOSPITAL NC INC CHRIST HOSPITAL NJ CHRIST HSP & MED CTR IL Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State NASHVILLE FRISCO LEXINGTON SANFORD SANFORD LANSDALE SOLDOTNA BARRE FREEHOLD COLORADO SPRINGS CHAMBERSBURG COUDERSPORT CHARLESTON TORRINGTON PUNTA GORDA CHESAPEAKE KEENE WEST CHESTER PITTSBURGH NEW ORLEANS OAKLAND CINCINNATI AKRON DETROIT PHILADELPHIA MILWAUKEE BOSTON AURORA BIRMINGHAM MADERA PITTSBURGH PITTSBURGH COLUMBUS NORFOLK SEATTLE PITTSBURGH DAYTON CHICAGO KANSAS CITY WASHINGTON MOUNTAINSIDE POMPTON PLAINS RICHMOND EDENTON JERSEY CITY OAK LAWN TN TX KY NC FL PA AK VT NJ CO PA PA WV CT FL VA NH PA PA LA CA OH OH MI PA WI MA CO AL CA PA PA OH VA WA PA OH IL MO DC NJ NJ VA NC NJ IL $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 8,508.57 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 7,067.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ ‐ $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 8,508.57 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 1,598.64 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 1,295.15 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 1,295.15 $ ‐ 4 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 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 $ 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 $ 466.08 $ 466.08 $ 674.25 $ 466.08 $ 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 $ 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 $ 100.25 $ 100.25 $ 136.06 $ 100.25 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 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 1.0684 0.8424 0.8424 0.8424 1.0684 0.8424 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 0.379209 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 0.379209 0.476642 0.476642 0.476642 0.379209 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name CHRISTIAN HOSP NORTHEAST MO CHRISTIANA CARE HLTH SERV DE CHRISTUS HLTH NORTHERN LOUISI CITRUS MEMORIAL HOSPITAL FL CITY HOSPITAL WV CLARA MAASS MEM HOSP CLARION HOSPITAL PA CLARION PSYCHIATRIC CTR PA CLEARFIELD HOSPITAL PA CLEVELAND CLINIC FOUNDATION CLEVELAND CLINIC HOSPITAL FL 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 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 COTTAGE HOSPITAL NH COVENANT HEALTHCARE MI COVENANT MEDICAL CENTER IA CREIGHTON UNIV MED CTR NE CRESTWOOD MEDICAL CENTER AL CROZER‐CHESTER MEDICAL CTR PA CULPEPER MEM HOSP VA Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State ST LOUIS WILMINGTON SHREVEPORT INVERNESS MARTINSBURG TOMS RIVER CLARION CLARION CLEARFIELD CLEVELAND WESTON CHARLOTTE COATESVILLE WALTERBORO SARASOTA RICHMOND WEST PALM BEACH WICHITA COLDWATER BOULDER INDIANAPOLIS OTTAWA OCEAN PORT SCRANTON SOUTH HILL FRESNO CONCORD JOHNSTOWN HARTFORD MARTINEZ CONWAY COOKEVILLE NORTHAMPTON CAMDEN MORRISVILLE CORAL GABLES CORAL SPRINGS CORRY COSHOCTON WOODSVILLE SAGINAW WATERLOO OMAHA HUNTSVILLE UPLAND CULPEPER MO DE LA FL WV NJ PA PA PA OH FL NC PA SC FL VA FL KS MI CO IN IL NJ PA VA CA NH PA CT CA SC TN MA NJ VT FL FL PA OH NH MI IA NE AL PA VA $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ 5 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 0.8424 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 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name 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 HOSPITAL AND MED CTR UT DAVIS MEMORIAL HOSPITAL WV DAY KIMBALL HOSPITAL CT DEACONESS HOSPITAL IN DEBORAH HEART AND LUNG CTR DECATUR GEN HOSPITAL AL 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 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 DYERSBURG HOSPITAL CORP TN EAST COOPER MEDICAL CTR SC 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 Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State NEW KENT LEAVENWORTH HOUSTON BOSTON DANBURY DANVILLE LAYTON ELKINS PUTNAM EVANSVILLE BROWNS MILLS DECATUR EL PASO DREXEL HILL DELTA PALM SPRINGS LAS VEGAS DETROIT ST GEORGE LANHAM AUGUSTA DALLAS MODESTO DOYLESTOWN DUBOIS RALEIGH DURHAM DURHAM DYERSBURG MT PLEASANT STATESBORO METAIRE EAST ORANGE KNOXVILLE IDAHO FALLS BANGOR ROSWELL EASTON LANSING ST PETERSBURG CHICAGO FLORENCE MANCHESTER MOUNTAIN HOME RIVERSIDE SMYRNA VA KS TX MA CT VA UT WV CT IN NJ AL TX PA CO CA NV MI UT MD GA TX CA PA PA NC NC NC TN SC GA LA NJ TN ID ME NM PA MI FL IL AL NH ID RI GA $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 8,508.57 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 7,067.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ ‐ $ ‐ $ ‐ $ 1,295.15 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ 6 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 $ 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 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 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 0.476642 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 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 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name EMORY UNIV HSP MIDTOWN 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 FAIRVIEW PARK HOSPITAL GA FAIRVIEW SOUTHDALE HSP MN FAIRVIEW UNIV MED CTR MN FAWCETT MEMORIAL HOSPITAL FL FAYETTE COUNTY HOSPITAL FEATHER RIVER HOSPITAL CA FIRELANDS REG MED CTR OH FIRST HEALTH OF CAROLINAS NC FLAGLER HOSPITAL FL FLAGSTAFF HOSP AND MED CTR AZ FLETCHER ALLEN HLTH ‐ MCHV FLORIDA HOSP HEARTLAND FL FLORIDA HOSP MED CTR FL FLORIDA HOSP WATERMAN FL FLORIDA HOSPITAL DELAND FL FLORIDA HOSPITAL ZEPHYR HILLS FLORIDA HSP FISH MEMORIAL FL FLOWER MEM HSP OH FLOWERS HOSPITAL AL FORT WASHINGTON HOSPITAL MD FOUNDATIONS BEHAVIORAL HEALTH FRANCISCAN HOSPITAL FOR CHILD FRANKLIN REGIONAL MEDICAL CTR FRANKLIN SQUARE HOSP MD FROEDTERT MEM LUTHER WI FRYE REGIONAL MED CTR NC 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 Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State ATLANTA ATLANTA ENGLEWOOD ENGLEWOOD EPHRATA WHEAT RIDGE DENVER FAIRBANKS FALLS CHURCH FAIRMONT CLEVELAND GT BARRINGTON PRINCETON DUBLIN EDINA MINNEAPOLIS PORT CHARLOTTE VANDALIA PARADISE SANDUSKY PINEHURST ST AUGUSTINE FLAGSTAFF BURLINGTON SEBRING ORLANDO TAVARES DELAND ZEPHYRHILLS ORANGE CITY SYLVANIA DOTHAN FORT WASHINGTON DOYLESTOWN BRIGHTON LOUISBURG BALTIMORE MILWAUKEE HICKORY GARDEN CITY GASTONIA CLARKSVILLE JUNCTION CITY DANVILLE WILKES BARRE WILKES BARRE GA GA FL NJ PA CO CO AK VA WV OH MA MN GA MN MN FL IL CA OH NC FL AZ VT FL FL FL FL FL FL OH AL MD PA MA NC MD WI NC MI NC TN KS PA PA PA $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 8,508.57 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,981.80 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ 298.23 $ 298.23 $ ‐ $ 1,295.15 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 726.75 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 298.23 7 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 $ 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 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 0.8424 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 0.379209 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 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 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name 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 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 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 HARRISON COUNTY COMM HSP MO HARTFORD HOSP CT HAZLETON GEN HSP PA HCA OAK HILL HOSP FL Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State ZANESVILLE GEORGETOWN WASHINGTON ALAMOGORDO GETTYSBURG LEHIGHTON CINCINNATI VINCENNES BALTIMORE DAYTON PUYALLUP WEST PALM BEACH DOWNERS GROVE ALLENTOWN TOWNSHEND ATLANTA MYRTLE BEACH SELLERSVILLE COLUMBUS BALTIMORE XENIA BOWLING GREEN GREENVILLE GREENWICH GREER DERBY LA CROSSE HACKENSACK HACKETTSTOWN MUSKEGON DAYTONA BEACH SOUTH BOSTON ERIE ROMNEY HANOVER SEATTLE ELIZABETHTOWN HAVRE DE GRACE HARLINGEN DETROIT SOUTHBRIDGE BEDFORD BETHANY HARTFORD HAZLETON BROOKSVILLE OH SC DC NM PA PA OH IN MD OH WA FL IL PA VT GA SC PA OH MD OH KY SC CT SC CT WI NJ NJ MI FL VA PA WV PA WA KY MD TX MI MA TX MO CT PA FL $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 8,508.57 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 8,508.57 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ 1,295.15 $ 298.23 $ 298.23 $ 298.23 $ 1,295.15 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ 8 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 674.25 $ 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 $ 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 $ 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 $ 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 1.0684 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 0.476642 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 0.379209 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 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name HEALTH ALLIANCE HOSP 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 HERITAGE HOSPITAL NC 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 IL 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 HOMESTEAD HOSPITAL FL HORIZON HSP SYSTMS PA HOSPITAL CORP/LAKEVIEW HSP UT HOSPITAL OF ST RAPHAEL CT HOSPITAL OF THE UNIV OF PENN HOSPITAL OF THE UNIV OF PENN HOWARD CTY GENERAL HSP MD HSP CENTRAL CT NEW BRIT HUGULEY MEMORIAL HOSPITAL TX HUMBOLDT GENERAL HSP NV HUNTERDON MEDICAL CENTER HUNTSVILLE HOSPITAL AL HURLEY MED CTR MI ILLINOIS MASONIC MED CTR IL IMPERIAL POINT HSP FL INDIANA REGIONAL MEDICAL CENT INGALLS MEMORIAL HOSPITAL IL INGHAM REGIONAL MEDICAL CENTE INTEGRIS BAPTIST MED CTR OK Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State LEOMINSTER FORT MYERS WOODBURY ERIE PLANO TARPON SPRINGS NAPOLEON DETROIT WYANDOTTE GARDNER TARBORO HIALEAH HIGH POINT CONNELLSVILLE BURIEN SIMPSONVILLE HINSDALE MELBOURNE KINGSPORT CHICAGO TAOS FT LAUDERDALE METHUEN TEANECK MEADOWBROOK CAMP HILL HOLYOKE HOMESTEAD GREENVILLE BOUNTIFUL NEW HAVEN PHILADELPHIA PHILADELPHIA COLUMBIA NEW BRITAIN FT WORTH WINNEMUCCA FLEMINGTON HUNTSVILLE FLINT CHICAGO FT LAUDERDALE INDIANA HARVEY LANSING OKLAHOMA CITY MA FL MN PA TX FL OH MI MI MA NC FL NC PA WA SC IL FL TN IL NM FL MA NJ PA PA MA FL PA UT CT PA PA MD CT TX NV NJ AL MI IL FL PA IL MI OK $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 7,067.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 9 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 $ 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 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 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 0.476642 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 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name 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 JASPER COUNTY HOSPITAL IN JAY HSP FL JEANES HOSPITAL PA JEFFERSON MEMORIAL HOSP MO JENNIE EDMUNDSON MEM HOSP IA JENNIE STUART MED CTR KY JERSEY CITY MEDICAL CTR NJ JERSEY SHORE MEDICAL CTR NJ JEWISH HOSPITAL KY 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 JUPITER MEDICAL CENTER FL KAPIOLANI MED PALI MOMI HI 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 KETTERING MED CTR OH KIMBALL MEDICAL CENTER KINGMAN REGIONAL MED CTR AZ KOOTENAI MEDICAL CENTER ID 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 Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State MURRAY DES MOINES STATESVILLE IRVINE ALTUS JACKSON MIAMI BALTIMORE RENSSELAER JAY PHILADELPHIA FESTUS COUNCIL BLUFFS HOPKINSVILLE JERSEY CITY NEPTUNE LOUISVILLE CINCINNATI PHOENIX PHOENIX FARMINGTON EDISON HOPEWELL BALTIMORE BALTIMORE JOHNSON CITY STAFFORD SPRINGS JUPITER AIEA MIAMI BALTIMORE STRATFORD WARWICK BAKERSFIELD CAMDEN WEST ORANGE KETTERING OCEAN PORT KINGMAN COEUR D ALENE LAFAYETTE ROWLETT SAINT JOSEPH LAKELAND FRANKLIN LACONIA UT IA NC CA OK TN FL MD IN FL PA MO IA KY NJ NJ KY OH AZ AZ CT NJ VA MD MD TN CT FL HI FL MD NJ RI CA SC NJ OH NJ AZ ID IN TX MI FL NH NH $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 7,067.51 $ 8,508.57 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 8,508.57 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 7,067.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 1,295.15 $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ 1,295.15 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ 10 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 $ 136.06 $ 136.06 $ 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 $ 136.06 $ 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 1.0684 1.0684 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 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 0.379209 0.379209 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 0.379209 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name 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 LITTLETON REGIONAL HOSP NH LOCK HAVEN HOSPITAL PA 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 LOS COLINAS MEDICAL CENTER TX LOUDOUN HOSPITAL CENTER VA LOUIS A WEISS MEMORIAL HOSP I LOURDES MED CTR BURLINGTON CT LOWELL GENERAL HOSPITAL MA 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 MAGEE WOMENS HOSPITAL PA MAIN LINE HSP LANKENAU PA MAINE GEN MED CTR ME MAINE MED CTR ME Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State LAKEWOOD LANCASTER WOONSOCKET LARGO EL PASO NEW LONDON LAWRENCE SALT LAKE CITY FORT MYERS LEESBURG PORTLAND PORTLAND TUALATIN GRESHAM ALLENTOWN BETHLEHEM KINSTON SPRINGFIELD SALEM WEST COLUMBIA LIBERTY WINSLOW LITTLETON LOCK HAVEN LODI LOMA LINDA LONG BEACH LONGMONT LORIS LOS ANGELES IRVING LEESBURG CHICAGO WILLINGBORO LOWELL PALO ALTO EAU CLAIRE CLEVELAND PARK RIDGE LYNCHBURG BERWYN PHILADELPHIA PITTSBURGH WYNNEWOOD WATERVILLE PORTLAND OH PA RI FL TX CT MA UT FL FL OR OR OR OR PA PA NC MO VA SC MO AZ NH PA CA CA CA CO SC CA TX VA IL NJ MA CA WI OH IL VA IL PA PA PA ME ME $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 11 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 0.8424 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 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name MANATEE MEMORIAL HSP FL MARCUS J LAWRENCE MEM HOSP AZ MARIA PARHAM HOSPITAL NC MARIAN COMMUNITY HOSPITAL PA MARICOPA MEDICAL CENTER AZ MARINERS HOSPITAL FL 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 MCKAY DEE HOSPITAL CTR UT 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 CENTER OF PLANO TX MEDICAL CTR CENTRAL GEORGIA G MEDICAL CTR OF ARLINGTON TX 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 HOSP TX 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 Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State BRADENTON COTTONWOOD HENDERSON CARBONDALE PHOENIX TAVERNIER MARLBOROUGH OAK BLUFFS LEBANON NEWPORT NEWS FREDERICKSBURG BALTIMORE CLEVELAND PORTSMOUTH BOSTON BOSTON PHOENIX JACKSONVILLE OGDEN LOVELAND DILLON FLORENCE SECAUCUS MEADVILLE MANSFIELD PRINCETON ODESSA MCKINNEY PLANO MACON ARLINGTON AURORA BRICK CHARLESTON MEDINA MELROSE HOUSTON KATY HOUSTON SAVANNAH CUMBERLAND SALEM PEMBROKE PINES MOUNT HOLLY BELLEVILLE MIRAMAR FL AZ NC PA AZ FL MA MA NH VA VA MD OH VA MA MA AZ FL UT CO SC SC NJ PA OH NJ TX TX TX GA TX CO NJ SC OH MA TX TX TX GA MD NJ FL NJ IL FL $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 7,067.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ 12 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 $ 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 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 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 0.476642 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 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 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name MEMORIAL HOSPITAL PA MEMORIAL HOSPITAL PA INC MEMORIAL HOSPITAL RI MEMORIAL HOSPITAL WEST FL MEMORIAL HSP CO MEMORIAL HSP MARTINSVILLE VA MEMORIAL HSP OF EASTON MD INC MEMORIAL MED CTR IL MEMORIAL MEDICAL CENTER IL MEMORIAL MISSION HOSPITAL NC 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 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 Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State YORK TOWANDA PAWTUCKET PEMBROKE PINES COLORADO SPRINGS MARTINSVILLE EASTON SPRINGFIELD WOODSTOCK ASHEVILLE HOLLYWOOD MENDOTA DARBY PHILADELPHIA CHARLOTTE SCRANTON GRAYLING COON RAPIDS TIFFIN WILLARD MASON CITY SIOUX CITY OSHKOSH SPRINGFIELD BALTIMORE ROSEBURG MONROE NORRISTOWN EUCLID MAYFIELD HTS EAST CLEVELAND MONTCLAIR FARGO HAVERHILL MESA MEMPHIS GARY INDIANAPOLIS CLEVELAND FRAMINGHAM KILLEEN MIAMI DAYTON MIDLAND PECKVILLE MIDDLETOWN PA PA RI FL CO VA MD IL IL NC FL IL PA PA NC PA MI MN OH OH IA IA WI MA MD OR MI PA OH OH OH NJ ND MA AZ TN IN IN OH MA TX FL OH MI PA CT $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 8,508.57 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 1,295.15 $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 13 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 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 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 0.476642 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 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name MIDDLETOWN REGIONAL HOSPITAL MIDSTATE MEDICAL CENTER CT MIDWEST CITY REGIONAL HOSP OK MILES MEMORIAL HOSPITAL ME MILFORD HOSPITAL CT MILLCREEK COMMUNITY HOSPITAL MILLINOCKET REGIONAL HSP ME MILTON S HERSHEY MED CTR PA MIMBRES MEMORIAL HOSP NM MIRIAM HOSPITAL RI MONADNOCK COMMUNITY HOSPITAL MONMOUTH MEDICAL CENTER NJ MONTGOMERY GENERAL HOSP MD MONTGOMERY HOSPITAL PA MONTROSE GENERAL HSP MOREHEAD MEM HSP NC MORGAN COUNTY MEM HOSPITAL IN MORRISTOWN MEMORIAL HOSP NJ MORTON PLANT HOSP FL 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 NASON HOSPITAL PA 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 Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State MIDDLETOWN MERIDEN MIDWEST CITY DAMARISCOTTA MILFORD ERIE MILLINOCKET HERSHEY DEMING PROVIDENCE PETERBOROUGH OCEANPORT OLNEY NORRISTOWN MONTROSE EDEN MARTINSVILLE MORRISTOWN CLEARWATER GREENSBORO SCRANTON COLUMBUS MIAMI BEACH MONTCLAIR WINDSOR COLUMBUS SAFFORD OCALA NACOGDOCHES SEAFORD NAPLES ROCKY MOUNT AYER MADISON ROARING SPRING NATCHEZ OREFIELD PHILADELPHIA OMAHA STOUGHTON NEW MILFORD OCEANPORT NEWPORT NEWTON NEWTON WESTFIELD OH CT OK ME CT PA ME PA NM RI NH NJ MD PA PA NC IN NJ FL NC PA OH FL NJ VT OH AZ FL TX DE FL NC MA TN PA MS PA PA NE MA CT NJ RI NJ MA MA $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 8,508.57 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 8,508.57 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 7,067.51 $ 8,508.57 $ 5,572.51 $ 7,067.51 $ 6,208.33 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 1,295.15 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 1,295.15 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 1,295.15 $ ‐ $ ‐ $ 298.23 $ ‐ 14 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 261.20 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 261.20 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 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 $ 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 $ 674.25 $ 674.25 $ 466.08 $ 674.25 $ 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 $ 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 $ 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 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 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 1.0684 1.0684 0.8424 1.0684 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 0.379209 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 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 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name 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 MEM MED CTR MN NORTH PHILADELPHIA HLTH SYS NORTH SHORE MED CTR FL NORTH SHORE MED CTR FMC FL NORTH SUBURBAN MED CTR CO NORTH VISTA HOSPITAL NV 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 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 OWENSBORO DAVIESS CTY HSP KY PALISADES MEDICAL CENTER NJ Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State NORTH ADAMS FAIRFIELD POMPANO BEACH WINSTON SALEM GREELEY NEWPORT NORTH RICHLAND HILLS ROBBINSDALE PHILADELPHIA MIAMI FT LAUDERDALE THORNTON N LAS VEGAS SPRINGFIELD ANNISTON SAN ANTONIO WILLCOX MOUNT AIRY SLIDELL EVANSTON ST PETERSBURG RANDALLSTOWN TUCSON AMARILLO SAINT ALBANS LOUISVILLE LOUISVILLE NORWALK OAKDALE TAYLOR DEARBORN NEW ORLEANS KENNER COLUMBUS WHEELING OLATHE PORT ANGELES ORLANDO KISSIMMEE OKLAHOMA CITY CAMDEN BATON ROUGE NAGS HEAD SUMMIT OWENSBORO NORTH BERGEN MA CA FL NC CO VT TX MN PA FL FL CO NV TN AL TX AZ NC LA IL FL MD AZ TX VT KY KY CT CA MI MI LA LA OH WV KS WA FL FL OK NJ LA NC NJ KY NJ $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 8,508.57 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 8,508.57 $ 5,572.51 $ 7,067.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 1,295.15 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 1,295.15 $ ‐ $ ‐ 15 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 261.20 $ 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 $ 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 $ 466.08 $ 674.25 $ 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 $ 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 $ 100.25 $ 136.06 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 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 0.8424 1.0684 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 0.476642 0.476642 0.476642 0.476642 0.476642 0.379209 0.476642 0.379209 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name 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 PARK PLAZA HOSPITAL TX PARKER ADVENTIST HEALTH CO PARKLAND MEDICAL CTR NH PARKLAND MEM HOSP TX PARKVIEW HSP ME PARKVIEW MED CTR CO PARKWEST MEDICAL CENTER TN PARRISH MED CTR FL 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 PHOENIXVILLE HOSP COMP PA 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 MATTHEWS NC PRESBYTERIAN HOSP NM PRESBYTERIAN HOSPITAL NC PRESBYTERIAN HSP OF DALLAS PRESBYTERIAN ST LUKES MED CO PRESBYTERIAN UNIV HSP PA PRESBYTERIAN UNIV HSP PA PRESBYTERIAN UNIV HSP PA Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State PALM BEACH GARDENS PALMERTON HIALEAH COLUMBIA SOUTH PASADENA ALBANY PAOLI HOUSTON PARKER DERRY DALLAS BRUNSWICK PUEBLO KNOXVILLE TITUSVILLE PORT CHARLOTTE SALISBURY PHILADELPHIA ROCKPORT ROXBORO KERRVILLE PHOENIX PHOENIX PHOENIXVILLE NAPLES ROCK HILL HARRISBURG WEST VALLEY CITY GREENVILLE PLANTATION E STROUDSBURG POMONA MIDDLEBURY LITTLETON POCATELLO KEYSER POTTSTOWN FORT COLLINS MATTHEWS ALBUQUERQUE CHARLOTTE DALLAS DENVER PITTSBURGH PITTSBURGH PITTSBURGH FL PA FL SC FL GA PA TX CO NH TX ME CO TN FL FL MD PA ME NC TX AZ AZ PA FL SC PA UT NC FL PA CA VT CO ID WV PA CO NC NM NC TX CO PA PA PA $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 298.23 16 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 0.8424 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 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name PRESBYTERIAN UNIV HSP PA PRESBYTERIAN UNIV HSP PA 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 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 Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State PITTSBURGH PITTSBURGH KINGWOOD CHEVERLY PRINCETON SOUTHFIELD HOLYOKE KANSAS CITY EL PASO PORTLAND OLYMPIA HONOLULU QUINCY EL PASO BECKLEY WYCKOFF RAPID CITY PERTH AMBOY READING SKOWHEGAN ORANGEBURG MEMPHIS HUDSON SAINT PAUL RENO RENO KANSAS CITY RALEIGH PROVIDENCE MEDIA MORENO VALLEY COLUMBUS NEWPORT NEWS TAPPAHANNOCK GLOUCESTER RED BANK AHOSKIE SAYRE RAHWAY NEW BRUNSWICK ROCKFORD HARRISONBURG PROVIDENCE MEDFORD LAMPASAS ROUND ROCK PA PA WV MD WV MI MA KS TX OR WA HI MA TX WV NJ SD NJ PA ME SC TN FL MN NV NV MO NC RI PA CA OH VA VA VA NJ NC PA NJ NJ IL VA RI OR TX TX $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 7,067.51 $ 6,208.33 $ 8,508.57 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 7,067.51 $ 5,572.51 $ 6,208.33 $ 7,067.51 $ 8,508.57 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 1,295.15 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 1,295.15 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ 17 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 261.20 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 261.20 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 674.25 $ 466.08 $ 466.08 $ 674.25 $ 674.25 $ 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 $ 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 $ 100.25 $ 100.25 $ 100.25 $ 136.06 $ 100.25 $ 100.25 $ 136.06 $ 136.06 $ 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 1.0684 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 1.0684 0.8424 0.8424 1.0684 1.0684 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 0.379209 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 0.476642 0.476642 0.476642 0.379209 0.476642 0.476642 0.379209 0.379209 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name ROXBOROUGH MEMORIAL HOSPITAL RUTLAND REG MED CTR SACRED HEART HOSPITAL PA SACRED HEART MED CTR UNIV DIS SAINT BARNABAS MEDICAL CENTER SAINT FRANCIS HOSPITAL TN SAINT LUKES SOUTH HSP INC KS SAINT VINCENTS HLTH CTR SAINTS 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 SANFORD JACKSON HOSP MN 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 SEVIER VALLEY MEDICAL CTR UT 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 SMYTH COUNTY COMMUNITY HOSP SOLDIERS AND SAILORS MEM HOSP SOMERSET MED CENTER NJ SOUTH BAY HOSP FL SOUTH CENTRAL REG MED CTR MS Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State PHILADELPHIA RUTLAND ALLENTOWN EUGENE OCEAN PORT MEMPHIS OVERLAND PARK ERIE LOWELL SALINA CLINTON UPLAND BAKERSFIELD SAN RAMON JACKSON SAN ANTONIO SARASOTA SCOTTSDALE SCOTTSDALE CHULA VISTA GREENWOOD VIRGINIA BEACH HAMPTON NORFOLK NORFOLK VIRGINIA BEACH WILLIAMSBURG ROUND ROCK DALY CITY AUSTIN RICHFIELD SEWICKLEY GAINESVILLE SHARON CHULA VISTA SAN DIEGO SIDNEY SOMERS POINT JOLIET DETROIT BRANSON MARION WELLSBORO SOMERVILLE SUN CITY CENTER LAUREL PA VT PA OR NJ TN KS PA MA KS NC CA CA CA MN TX FL AZ AZ CA SC VA VA VA VA VA VA TX CA TX UT PA FL CT CA CA OH NJ IL MI MO VA PA NJ FL MS $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 7,067.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ 18 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 $ 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 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 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 0.476642 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 0.379209 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name SOUTH COUNTY HOSPTAL RI SOUTH FLORIDA BAPTIST HSPFL SOUTH FULTON MEDICAL CR GA SOUTH LAKE HSP FL SOUTH MIAMI HOSPITAL FL SOUTH POINTE HOSPITAL OH SOUTH SHORE HOSP MA SOUTHCREST HSP OK SOUTHEASTERN OHIO REG MED CTR SOUTHEASTERN REG MED CTR NC SOUTHERN HILLS 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 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 MN ST FRANCIS MEDICAL CENTER NE ST JAMES HLTH CAREHSP MT Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State WAKEFIELD PLANT CITY EAST POINT CLERMONT SOUTH MIAMI WARRENSVILLE HTS SOUTH WEYMOUTH TULSA CAMBRIDGE LUMBERTON LAS VEGAS NASHVILLE BIDDEFORD CLINTON NASHUA MANAHAWKIN SAN ANTONIO CLEVELAND CORTEZ VANCOUVER BENNINGTON SPARTANBURG PLYMOUTH LAS VEGAS SPRINGFIELD SAINT LOUIS BOISE FALL RIVER DENVER FRISCO EAST CHICAGO PHILADELPHIA DENVILLE SAINT CLOUD JACKSON YOUNGSTOWN LAFAYETTE APPLETON EDGEWOOD HARTFORD TULSA WILMINGTON TRENTON BRECKENRIDGE GRAND ISLAND BUTTE RI FL GA FL FL OH MA OK OH NC NV TN ME MD NH NJ TX OH CO WA VT SC NH NV MA MO ID MA CO CO IN PA NJ MN MS OH IN WI KY CT OK DE NJ MN NE MT $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ 19 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 0.8424 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 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name 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 EAST LEES HSP MO ST LUKES HOSP WEST KY ST LUKES HOSPITAL ST LUKES HOSPITAL ST LUKES HOSPITAL OH ST LUKES MED CTR AZ ST LUKES NORTHLAND HSP MO ST MARGARET MERCY HLTH IN ST MARKS HOSPITAL UT ST MARY HOSPITAL PA ST MARY 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 EVANSVLLE IN 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 RITAS MEDICAL CENTER OH 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 Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State LEAVENWORTH SPRINGFIELD SAINT LOUIS SPRINGFIELD JOPLIN READING BELLINGHAM PONTIAC NORTH PROVIDENCE PATERSON TAMPA SAVANNAH MISHAWAKA WAYNE MEMPHIS SAINT LOUIS THE WOODLANDS LEES SUMMIT FLORENCE BETHLEHEM MILWAUKEE MAUMEE PHOENIX SMITHVILLE DYER SALT LAKE CITY LANGHORNE HOBOKEN LIVONIA KNOXVILLE PASSAIC WATERBURY RICHMOND EVANSVILLE HOBART WEST PALM BEACH NUTLEY NEW BRUNSWICK ST PETERSBURG LIMA HAYWARD CANON CITY CLEVELAND WORCESTER INDIANAPOLIS BRIDGEPORT KS IL MO MO MO PA WA MI RI NJ FL GA IN NJ TN MO TX MO KY PA WI OH AZ MO IN UT PA NJ MI TN NJ CT VA IN IN FL NJ NJ FL OH CA CO OH MA IN CT $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 8,508.57 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 7,067.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 7,067.51 $ 5,572.51 $ 5,572.51 $ 7,067.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 7,067.51 $ 7,067.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 8,508.57 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 1,295.15 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 1,295.15 20 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 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 $ 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 $ 674.25 $ 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 $ 674.25 $ 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 $ 136.06 $ 100.25 $ 100.25 $ 136.06 $ 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 $ 136.06 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 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 1.0684 0.8424 0.8424 1.0684 0.8424 0.8424 0.8424 0.8424 0.8424 1.0684 1.0684 0.8424 0.8424 0.8424 0.8424 0.8424 0.8424 0.8424 1.0684 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 0.379209 0.476642 0.476642 0.379209 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 0.379209 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name STAFFORD HOSPITAL VA STAMFORD HOSPITAL CT STANLY MEMORIAL HOSPITAL NC STEPHENS MEMORIAL HSP STEVENS HOSPITAL WA STEWARD CARNEY HOSP MA STEWARD GOOD SAM MED CTR MA STEWARD GOOD SAM MED CTR MA STEWARD HOLY FAMILY MA 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 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 TRUMAN MEDICAL CENTER MO 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 Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State STAFFORD STAMFORD ALBEMARLE NORWAY EDMONDS DORCHESTER BROCKTON BROCKTON METHUEN STILLWATER NORTH STONINGTON TOPEKA LOUISVILLE ATTLEBORO BETHESDA LAS VEGAS HERMITAGE SUN CITY LAS VEGAS SWEETWATER TAMPA PHILADELPHIA BRISTOL PHILADELPHIA HOUSTON PHILADELPHIA GRANTS PASS TOLEDO TAMPA CHARLESTON ELIZABETH TROY KANSAS CITY WARREN TUCSON WORCESTER SUMTER TUNKHANNOCK TORRANCE SAN DIEGO WORCESTER WORCESTER WOODBURY ELKTON BALTIMORE SAINT PAUL VA CT NC ME WA MA MA MA MA OK CT KS KY MA MD NV TN AZ NV TN FL PA PA PA TX PA OR OH FL SC NJ PA MO OH AZ MA SC PA CA CA MA MA NJ MD MD MN $ 5,572.51 $ 8,508.57 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 8,508.57 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ 1,295.15 $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ 1,295.15 $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ 298.23 $ 298.23 21 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 $ 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 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 0.8424 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 0.476642 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 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 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name 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 SO ALABAMA WOMEN&CHILD UNIV WICSONSIN HSP & CLINICS UNIVERSITY COMM HOSP FL UNIVERSITY HOSPITAL NC 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 VHS CHILDRENS HSP MI VILLAGES REGIONAL HOSP FL VIRGINIA BEACH PSYCHIATRIC WACCAMAW COMM HSP SC WAHIAWA GEN HSP HI WAKEMED HEALTH AND HOSP NC Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State CLARKSBURG WICHITA FALLS FRIDLEY SACRAMENTO LEXINGTON LAS VEGAS BIRMINGHAM CHICAGO JACKSON IOWA CITY NEWARK ALBUQUERQUE CHAPEL HILL TOLEDO CHARLOTTESVILLE MOBILE MADISON TAMPA CHARLOTTE DENVER AUGUSTA SAN ANTONIO LUBBOCK TUCSON FRESNO KANSAS CITY BALTIMORE ANN ARBOR KNOXVILLE SALT LAKE CITY BALTIMORE PHILADELPHIA PITTSBURGH BEL AIR TROY PROVO RIDGEWOOD LAS VEGAS GLENWOOD SPRINGS NASHVILLE DETROIT THE VILLAGES VIRGINIA BEACH MURRELLS INLET WAHIAWA RALEIGH WV TX MN CA KY NV AL IL MS IA NJ NM NC OH VA AL WI FL NC CO GA TX TX AZ CA KS MD MI TN UT MD PA PA MD OH UT NJ NV CO TN MI FL VA SC HI NC $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 8,508.57 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 7,067.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 1,295.15 $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 22 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 261.20 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 674.25 $ 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 $ 136.06 $ 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 1.0684 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 0.379209 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 04/01/11 ‐ 09/30/11 Hospital Name 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 WEIRTON MEDICAL CTR WV WELLSTAR COBB HOSP GA WENTWORTH DOUGLASS HOSP NH WEST ALLIS MEMORIAL HOSP WI WEST GROVE/JENNERSVILLE PA WEST JEFFERSON MED CTR LA WEST JERSEY HEALTH SYS WEST VALLEY HOSPITAL AZ WESTBOROUGH STATE HOSPITAL MA WESTERLY HOSP RI WESTERN PENNSYLVANIA HOSP WESTSIDE REGIONAL MED CTR FL WHEATON FRANCISCAN WI WHIDBEY GENERAL HOSPITAL WA WICKENBURG COMM HOSP AZ WILLIAM BACKUS HOSPITAL CT WILLIAM BEAUMONT HOSP WILLIAMSPORT HOSPITAL PA WINDBER HOSPITAL PA WINDHAM COMMUNITY MEM HOSPITA WING MEMORIAL HOSPITAL MA WOMEN & INFANTS HSP RI WOOD CTY HSP OH WVHCS HOSP WILKES BARRE PA WYTHE COUNTY COMM HOSP VA YALE NEW HAVEN HOSPITAL CT YAVAPAI REG MED CTR AZ YORK HOSPITAL Rate Code 2953 Rate Code 2952 (OOS Hospital (OOS Hospital DRG) Exempt) City, State MONROE WARREN PHILLIPSBURG PLYMOUTH WASHINGTON WASHINGTON WATERBURY WAUKESHA HONESDALE WAYNESBORO GOLDSBORO WAYNESBORO WEIRTON AUSTELL DOVER WEST ALLIS WEST GROVE MARRERO VOORHEES TOWNSHIP GOODYEAR WESTBOROUGH WESTERLY PITTSBURGH PLANTATION MILWAUKEE COUPEVILLE WICKENBURG NORWICH ROYAL OAK WILLIAMSPORT WINDBER WILLIMANTIC PALMER PROVIDENCE BOWLING GREEN WILKES BARRE WYTHEVILLE NEW HAVEN PRESCOTT YORK GA PA NJ NC DC PA CT WI PA TN NC PA WV GA NH WI PA LA NJ AZ MA RI PA FL WI WA AZ CT MI PA PA CT MA RI OH PA VA CT AZ PA $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 6,208.33 $ 5,572.51 $ 5,572.51 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ 5,572.51 $ 6,208.33 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ Rate Code 2589 (DME Add‐on) $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ 298.23 $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ 298.23 $ ‐ $ ‐ $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 $ ‐ $ 298.23 23 of 23 Rate Code Rate Code 2951 and 2955 Rate Code 2990 Rate Code 2991 WEF/ISAF High Cost (ALC Home (Capital per (Capital per (for High Cost Charge 2950 and 2954 (ALC RHCF) Care) Disch) Diem) Claims) Convertors $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 171.74 $ 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 $ 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 $ 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 0.8424 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 0.476642 0.476642 oos_4_1_11_in_3_20_12.xls
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