Prospective Payment System (PPS) definition

Prospective Payment System (PPS) means a method of reimbursement in which payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service – for example, diagnosis-related groups for inpatient hospital services. Provider means an institution, facility, agency, physician, health care practitioner, or other entity that is licensed or otherwise authorized to provide any of the Covered Services in the state in which they are furnished. Providers include individuals and vendors providing services to Members through the Self-Directed Community Benefit. Provider Preventable Conditions (PPC) means a condition that meets the definition of Health Care Acquired Conditions or Other Provider Preventable Conditions. Provider Satisfaction Survey shall have the meaning ascribed to such term in Section 4.12.6 of this Agreement. Provider Workgroup means the workgroup consisting of representatives from each Centennial Care MCO, HSD, the Collaborative and Providers to work collaboratively to reduce administrative burdens on Providers by, among other things, standardizing forms and processes. Psychotropic Drugs and Medications means the therapeutic classes of drugs and the medications listed in Attachment 8 of this document, or the equivalent classes of drugs in other therapeutic classification systems. QM/QI means quality management and quality improvement. Quantitative Treatment Limits (QTL) Numerical limits on benefits or services based on frequency of treatment, number of days, days of coverage, days in a waiting period or similar limits on treatment scope or duration. RAC means the Medicaid Recovery Audit Contractor.

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Prospective Payment System (PPS). A method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, DRGs for inpatient hospital services). CMS uses separate PPSs for reimbursement to acute inpatient hospitals, home health agencies, hospice, hospital outpatient, inpatient psychiatric facilities, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities. Provider: Any physician, hospital, facility, or other Health Care Professional who is licensed or otherwise authorized to provide Health Care services in the State or jurisdiction in which they are furnished. Provider Complaint: A written expression by a Provider, which indicates dissatisfaction or dispute with the Contractor’s policies, procedures, or any aspect of a Contractor’s administrative functions, including a Proposed Action.

Prospective Payment System (PPS) means a system that sets payment rates for a predetermined period for defined services, before the services are provided. The payment rates are based on economic forecasts and the projected cost of ser- vices for the predetermined period.

Examples of Prospective Payment System (PPS) in a sentence

• However, this payment will be limited so that the total payment received by the Provider for a service, including payment from all sources, does not exceed the Prospective Payment System (PPS) utilizing Diagnosis Related Groupings (DRG) reimbursement for that service.

• FQHC and RHCs The CONTRACTOR shall reimburse both Contract and Non-Contract FQHCs and RHCs at a minimum of the Prospective Payment System (PPS) or alternative payment methodology in compliance with Section 1905(a)(2)(C) of the Social Security Act.

• The Provider agrees that receipt of the lesser of 50% of the deductible amount or an amount sufficient to bring the total payment received by the Provider up to the level of the Prospective Payment System (PPS) utilizing Diagnosis Related Groupings (DRG) reimbursement for the service being billed constitutes payment in full, and the Provider may neither request nor accept further payment from the patient.

• The Provider agrees that receipt of the lesser of 50% of the coinsurance amount or an amount sufficient to bring the total payment received by the Provider up to the level of the Prospective Payment System (PPS) utilizing Diagnosis Related Groupings (DRG) reimbursement for the service being billed constitutes payment in full, and the Provider may neither request nor accept further payment from the patient.

• Average Patient Visits Per Half Day (APVPHD) is determined by the number of billable face-to-face (including billable telemedicine at the full Prospective Payment System (PPS) rate) patient encounters per one half day of scheduled patient care time in primary care.

• Dialysis Services Payment is defined as the current payment that Provider will receive from Company for dialysis services based on CMS's ESRD Prospective Payment System (PPS).

• OHA will provide Contractor with the IHS and Prospective Payment System (PPS) encounter rates for IHCPs upon request.

• The Department will process hospital claims (including inpatient hospital services and services provided in a short procedure unit, ambulatory surgical center, and/or independent medical/surgical unit) by using a Prospective Payment System (PPS) utilizing Diagnosis Related Groupings (DRG).

• BCBSM will determine Provider’s payment rate in accordance with the requirements of the Affordable Care Act and Medicare Federally Qualified Health Center Prospective Payment System (PPS) method of reimbursement.

• Under the Consolidated Billing provisions of the SNF Prospective Payment System (PPS), there may be specific services provided by the Supplier to inpatients of the SNF, covered under Medicare Part A at the time the services are provided, that are the financial responsibility of the SNF.