{"component": "definition", "props": {"groups": [{"snippet": "and \u201cPPS\u201d each means the payment methodology described in 42 USC 1396a(bb) that is applicable to Federally Qualified Health Centers and Rural Health Centers.", "size": 9, "snippet_links": [{"key": "payment-methodology", "type": "clause", "offset": [25, 44]}, {"key": "applicable-to", "type": "clause", "offset": [83, 96]}, {"key": "federally-qualified-health-centers", "type": "definition", "offset": [97, 131]}, {"key": "rural-health", "type": "clause", "offset": [136, 148]}], "samples": [{"hash": "i2BbMmWjRKQ", "uri": "/contracts/i2BbMmWjRKQ#prospective-payment-system", "label": "Health Plan Services Contract", "score": 33.5274978207, "published": true}, {"hash": "7eH6hfttFpY", "uri": "/contracts/7eH6hfttFpY#prospective-payment-system", "label": "Health Plan Services Contract", "score": 33.5274978207, "published": true}, {"hash": "cLlAuDMivLv", "uri": "/contracts/cLlAuDMivLv#prospective-payment-system", "label": "Health Plan Services Contract", "score": 33.5194582535, "published": true}], "hash": "9b1d8e5279a88e6d098777f0e45d215c", "id": 1}, {"snippet": "(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 \u2013 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.", "size": 4, "snippet_links": [{"key": "method-of-reimbursement", "type": "clause", "offset": [14, 37]}, {"key": "based-on", "type": "clause", "offset": [63, 71]}, {"key": "fixed-amount", "type": "definition", "offset": [89, 101]}, {"key": "payment-amount", "type": "definition", "offset": [107, 121]}, {"key": "classification-system", "type": "clause", "offset": [171, 192]}, {"key": "for-example", "type": "clause", "offset": [211, 222]}, {"key": "inpatient-hospital-services", "type": "definition", "offset": [253, 280]}, {"key": "health-care-practitioner", "type": "definition", "offset": [342, 366]}, {"key": "other-entity", "type": "clause", "offset": [371, 383]}, {"key": "to-provide", "type": "definition", "offset": [425, 435]}, {"key": "in-the-state", "type": "definition", "offset": [464, 476]}, {"key": "services-to-members", "type": "clause", "offset": [558, 577]}, {"key": "community-benefit", "type": "definition", "offset": [604, 621]}], "samples": [{"hash": "1nxPPXC9Jlw", "uri": "/contracts/1nxPPXC9Jlw#prospective-payment-system", "label": "Medicaid Managed Care Services Agreement", "score": 32.805762898, "published": true}, {"hash": "bgTASXFayAm", "uri": "/contracts/bgTASXFayAm#prospective-payment-system", "label": "Medicaid Managed Care Services Agreement", "score": 32.7400602786, "published": true}, {"hash": "gyRK0n50O0u", "uri": "/contracts/gyRK0n50O0u#prospective-payment-system", "label": "Medicaid Managed Care Services Agreement", "score": 32.5648532936, "published": true}], "hash": "ddd1a4bd415db29e4faeee059940e3b5", "id": 2}, {"snippet": "(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 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 (HCAC) or Other Provider Preventable Conditions. Provider Satisfaction Survey shall have the meaning ascribed to such term in Section 4.12.6 of this Agreement.", "size": 4, "snippet_links": [{"key": "method-of-reimbursement", "type": "clause", "offset": [14, 37]}, {"key": "based-on", "type": "clause", "offset": [63, 71]}, {"key": "fixed-amount", "type": "definition", "offset": [89, 101]}, {"key": "payment-amount", "type": "definition", "offset": [107, 121]}, {"key": "health-care-practitioner", "type": "definition", "offset": [210, 234]}, {"key": "other-entity", "type": "clause", "offset": [239, 251]}, {"key": "to-provide", "type": "definition", "offset": [293, 303]}, {"key": "in-the-state", "type": "definition", "offset": [332, 344]}, {"key": "services-to-members", "type": "clause", "offset": [426, 445]}, {"key": "community-benefit", "type": "definition", "offset": [472, 489]}, {"key": "the-definition-of", "type": "definition", "offset": [558, 575]}, {"key": "health-care-acquired-conditions", "type": "clause", "offset": [576, 607]}, {"key": "other-provider-preventable-conditions", "type": "clause", "offset": [618, 655]}, {"key": "provider-satisfaction-survey", "type": "clause", "offset": [657, 685]}, {"key": "this-agreement", "type": "clause", "offset": [752, 766]}], "samples": [{"hash": "coRp24S3xcQ", "uri": "/contracts/coRp24S3xcQ#prospective-payment-system", "label": "Medicaid Managed Care Services Agreement", "score": 35.3697103811, "published": true}, {"hash": "1a5BHix8UKv", "uri": "/contracts/1a5BHix8UKv#prospective-payment-system", "label": "Medicaid Managed Care Services Agreement", "score": 35.267961165, "published": true}, {"hash": "5Jj6TEmzhDE", "uri": "/contracts/5Jj6TEmzhDE#prospective-payment-system", "label": "Medicaid Managed Care Services Agreement", "score": 35.1589144772, "published": true}], "hash": "fd7542a10048ef2e042cb2fc1afd9ad6", "id": 3}, {"snippet": "means a system of classifying episodes of care for billing and reimbursement pur- poses, based on factors such as diagnoses, age, and sex.", "size": 4, "snippet_links": [{"key": "billing-and-reimbursement", "type": "clause", "offset": [51, 76]}, {"key": "based-on", "type": "clause", "offset": [89, 97]}], "samples": [{"hash": "8qZMhe8kQwX", "uri": "https://apps.azsos.gov/public_services/register/2007/44/final.pdf", "label": "apps.azsos.gov", "score": 10.1704312115, "published": false}, {"hash": "34EVCDlcn6k", "uri": "https://apps.azsos.gov/public_services/register/2007/26/proposed.pdf", "label": "apps.azsos.gov", "score": 5.0, "published": false}], "hash": "483d0a4dd560b642733184404d507390", "id": 4}, {"snippet": "(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 \u2013 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.", "size": 3, "snippet_links": [{"key": "method-of-reimbursement", "type": "clause", "offset": [14, 37]}, {"key": "based-on", "type": "clause", "offset": [63, 71]}, {"key": "fixed-amount", "type": "definition", "offset": [89, 101]}, {"key": "payment-amount", "type": "definition", "offset": [107, 121]}, {"key": "classification-system", "type": "clause", "offset": [171, 192]}, {"key": "for-example", "type": "clause", "offset": [211, 222]}, {"key": "inpatient-hospital-services", "type": "definition", "offset": [253, 280]}, {"key": "health-care-practitioner", "type": "definition", "offset": [342, 366]}, {"key": "other-entity", "type": "clause", "offset": [371, 383]}, {"key": "to-provide", "type": "definition", "offset": [425, 435]}, {"key": "in-the-state", "type": "definition", "offset": [464, 476]}, {"key": "services-to-members", "type": "clause", "offset": [558, 577]}, {"key": "community-benefit", "type": "definition", "offset": [604, 621]}, {"key": "the-definition-of", "type": "definition", "offset": [690, 707]}, {"key": "health-care-acquired-conditions", "type": "clause", "offset": [708, 739]}, {"key": "other-provider-preventable-conditions", "type": "clause", "offset": [743, 780]}, {"key": "provider-satisfaction-survey", "type": "clause", "offset": [782, 810]}, {"key": "this-agreement", "type": "clause", "offset": [877, 891]}, {"key": "provider-workgroup", "type": "definition", "offset": [893, 911]}, {"key": "of-representatives", "type": "clause", "offset": [943, 961]}, {"key": "centennial-care", "type": "definition", "offset": [972, 987]}, {"key": "the-collaborative", "type": "definition", "offset": [998, 1015]}, {"key": "drugs-and-medications", "type": "clause", "offset": [1172, 1193]}, {"key": "therapeutic-classes", "type": "definition", "offset": [1204, 1223]}, {"key": "quality-management-and-quality-improvement", "type": "clause", "offset": [1386, 1428]}, {"key": "limits-on", "type": "clause", "offset": [1476, 1485]}, {"key": "frequency-of", "type": "clause", "offset": [1516, 1528]}, {"key": "number-of-days", "type": "definition", "offset": [1540, 1554]}, {"key": "days-in", "type": "definition", "offset": [1574, 1581]}, {"key": "waiting-period", "type": "clause", "offset": [1584, 1598]}, {"key": "recovery-audit-contractor", "type": "definition", "offset": [1672, 1697]}], "samples": [{"hash": "gQ7Bx9NGwUH", "uri": "/contracts/gQ7Bx9NGwUH#prospective-payment-system", "label": "Medicaid Managed Care Services Agreement", "score": 33.9926929831, "published": true}, {"hash": "aeaPc7gG9fh", "uri": "/contracts/aeaPc7gG9fh#prospective-payment-system", "label": "Medicaid Managed Care Services Agreement", "score": 33.9926929831, "published": true}, {"hash": "bq8Xv2mgV3q", "uri": "/contracts/bq8Xv2mgV3q#prospective-payment-system", "label": "Medicaid Managed Care Services Agreement", "score": 33.733504298, "published": true}], "hash": "05454d19f783ed05eeb80300bcd2ca8a", "id": 5}, {"snippet": "or \u201cPPS\u201d means a cost-based, per clinic rate that applies uniformly to all CCBHC services rendered by a certified clinic, including those delivered by qualified satellite facilities established prior to April 1, 2014. In demonstration year one (DY1), the state uses cost and visit data from the demonstration planning phase, updated by the Medicare Economic Index (MEI) to create the rate for DY1. The DY1 rate will be updated again for future demonstration years by rebasing the PPS rate.", "size": 2, "snippet_links": [{"key": "services-rendered", "type": "definition", "offset": [81, 98]}, {"key": "prior-to", "type": "clause", "offset": [194, 202]}, {"key": "april-1", "type": "definition", "offset": [203, 210]}, {"key": "year-one", "type": "definition", "offset": [235, 243]}, {"key": "the-state", "type": "clause", "offset": [251, 260]}, {"key": "planning-phase", "type": "definition", "offset": [309, 323]}, {"key": "medicare-economic-index", "type": "definition", "offset": [340, 363]}, {"key": "the-rate", "type": "clause", "offset": [380, 388]}, {"key": "demonstration-years", "type": "clause", "offset": [444, 463]}], "samples": [{"hash": "3Kw9pz0zZND", "uri": "https://hhs.iowa.gov/media/14163/download?inline=", "label": "hhs.iowa.gov", "score": 19.3011140491, "published": false}, {"hash": "GuaYxnScEq", "uri": "https://hhs.iowa.gov/media/13543/download?inline", "label": "hhs.iowa.gov", "score": 19.1143926254, "published": false}], "hash": "a17e1ca7635fc211692c6045b3c6925d", "id": 6}, {"snippet": "or \u201cPPS\u201d means the Medicare prospective payment system under which a provider is paid a predetermined amount per patient, either per day or per encounter, based on the anticipated costs of treating a patient (rather than on a retrospective cost-based methodology) by classifying each patient into certain clinical categories reflecting the patient\u2019s acuity level;", "size": 2, "snippet_links": [{"key": "per-day", "type": "definition", "offset": [129, 136]}, {"key": "based-on", "type": "clause", "offset": [155, 163]}, {"key": "costs-of", "type": "definition", "offset": [180, 188]}, {"key": "clinical-categories", "type": "definition", "offset": [305, 324]}, {"key": "acuity-level", "type": "definition", "offset": [350, 362]}], "samples": [{"hash": "cTbDeYsxkC1", "uri": "https://www.sec.gov/Archives/edgar/data/1012881/000090956707000561/o35413exv99w4.htm", "label": "Explanatory Note (Extendicare Real Estate Investment Trust)", "score": 7.0, "published": false}], "hash": "7214c927082927604ff98c3f07712146", "id": 7}, {"snippet": "means a predetermined amount of reimbursement per day for inpatient hospital services.", "size": 1, "snippet_links": [{"key": "amount-of-reimbursement", "type": "clause", "offset": [22, 45]}, {"key": "per-day", "type": "definition", "offset": [46, 53]}, {"key": "inpatient-hospital-services", "type": "definition", "offset": [58, 85]}], "samples": [{"hash": "bMYxcljYzNQ", "uri": "https://msa.maryland.gov/megafile/msa/speccol/sc5300/sc5339/000113/021600/021615/20170007e.pdf", "label": "msa.maryland.gov", "score": 7.6310746064, "published": false}], "hash": "3fd80fa7f6172c6aae9f98e028ebbf3d", "id": 8}, {"snippet": "means a system of classi- fying episodes of care for billing and reimbursement pur- poses, based on factors such as diagnoses, age, and sex.", "size": 1, "snippet_links": [{"key": "billing-and-reimbursement", "type": "clause", "offset": [53, 78]}, {"key": "based-on", "type": "clause", "offset": [91, 99]}], "samples": [{"hash": "Nq0OJHFZKs", "uri": "https://apps.azsos.gov/public_services/Title_09/9-11.pdf", "label": "Notice", "score": 11.4106776181, "published": false}], "hash": "26c6dc277cd8044d2acde57eb9455f65", "id": 9}, {"snippet": "(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\u2019s policies, procedures, or any aspect of a Contractor\u2019s administrative functions, including a Proposed Action.", "size": 1, "snippet_links": [{"key": "method-of-reimbursement", "type": "clause", "offset": [9, 32]}, {"key": "medicare-payment", "type": "clause", "offset": [42, 58]}, {"key": "based-on", "type": "clause", "offset": [67, 75]}, {"key": "fixed-amount", "type": "definition", "offset": [93, 105]}, {"key": "payment-amount", "type": "definition", "offset": [111, 125]}, {"key": "classification-system", "type": "clause", "offset": [175, 196]}, {"key": "for-example", "type": "clause", "offset": [214, 225]}, {"key": "inpatient-hospital-services", "type": "definition", "offset": [236, 263]}, {"key": "home-health-agencies", "type": "clause", "offset": [337, 357]}, {"key": "hospital-outpatient", "type": "clause", "offset": [368, 387]}, {"key": "inpatient-psychiatric-facilities", "type": "clause", "offset": [389, 421]}, {"key": "inpatient-rehabilitation", "type": "definition", "offset": [423, 447]}, {"key": "term-care", "type": "clause", "offset": [465, 474]}, {"key": "skilled-nursing-facilities", "type": "clause", "offset": [490, 516]}, {"key": "health-care-professional", "type": "clause", "offset": [572, 596]}, {"key": "to-provide", "type": "definition", "offset": [637, 647]}, {"key": "state-or-jurisdiction", "type": "definition", "offset": [676, 697]}, {"key": "provider-complaint", "type": "definition", "offset": [727, 745]}, {"key": "the-contractor", "type": "definition", "offset": [831, 845]}, {"key": "a-contractor", "type": "clause", "offset": [887, 899]}, {"key": "administrative-functions", "type": "definition", "offset": [902, 926]}, {"key": "proposed-action", "type": "clause", "offset": [940, 955]}], "samples": [{"hash": "9ecLUttQrYT", "uri": "/contracts/9ecLUttQrYT#prospective-payment-system", "label": "Contract (Centene Corp)", "score": 19.0, "published": true}], "hash": "76b8ff0b0eb117a80290e4c0d01a3e42", "id": 10}], "next_curs": "CmcSYWoVc35sYXdpbnNpZGVyY29udHJhY3RzckMLEhpEZWZpbml0aW9uU25pcHBldEdyb3VwX3Y1NiIjcHJvc3BlY3RpdmUtcGF5bWVudC1zeXN0ZW0jMDAwMDAwMGEMogECZW4YACAA", "definition": {"title": "Prospective Payment System", "snippet": "and \u201cPPS\u201d each means the payment methodology described in 42 USC 1396a(bb) that is applicable to Federally Qualified Health Centers and Rural Health Centers.", "size": 33, "id": "prospective-payment-system", "examples": ["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 <strong>Prospective Payment System</strong> (PPS) utilizing Diagnosis Related Groupings (DRG) reimbursement for that service.", "The methadone per diem rate for OTPs will be updated annually by the Medicare update factor used for their Inpatient <strong>Prospective Payment System</strong> (IPPS).", "For acute care hospitals that qualify as a \u201cRural Provider\u201d under the North Carolina State Health Plan Pricing Policy, outpatient services identified by CMS Outpatient <strong>Prospective Payment System</strong> (OPPS) Status codes will be priced based on 235% of the then current Medicare APC allowable rates, geographically adjusted.", "For professional services billed on a CMS-1500 or successor form, 160%, and for technical services billed on a UB-04 form, 200% of current rate under the Medicare FQHC <strong>Prospective Payment System</strong>.", "Average Patient Visits Per Half Day (APVPHD) is determined by the number of billable face-to-face (including billable telemedicine at the full <strong>Prospective Payment System</strong> (PPS) rate) patient encounters per one half day of scheduled patient care time in primary care.", "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 <strong>Prospective Payment System</strong> (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.", "For acute care hospitals that do not qualify as a \u201cRural Provider\u201d under the North Carolina State Health Plan Pricing Policy, outpatient services identified by CMS Outpatient <strong>Prospective Payment System</strong> (OPPS) Status codes will be priced based on 225% of the then current Medicare APC allowable rates, geographically adjusted.", "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 <strong>Prospective Payment System</strong> (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.", "For other provider types, the Medicare allowable rate is based upon CMS Geographic Pricing Cost Indices (GPCI) and Resource Based Relative Value Scale (RBRVS) Relative Value Units (RVU) including Outpatient <strong>Prospective Payment System</strong> (OPPS) cap rates; the Clinical Laboratory Fee Schedule (CLAB); the Durable Medical Equipment, Prosthetics, Orthotics and Supplies Fee Schedule; including PEN (DMEPOS) and \u2018Medicare Part B Drug Average Sales Price (ASP),\u2019 as appropriate.", "FQHC and RHCs The CONTRACTOR shall reimburse both Contract and Non-Contract FQHCs and RHCs at a minimum of the <strong>Prospective Payment System</strong> (PPS) or alternative payment methodology in compliance with Section 1905(a)(2)(C) of the Social Security Act."], "related": [["payment-system", "payment system", "payment system"], ["cash-payment-system", "Cash Payment System", "Cash Payment System"], ["retirement-system", "Retirement system", "Retirement system"], ["settlement-system-code", "Settlement System Code", "Settlement System Code"], ["electronic-payment-system", "Electronic Payment System", "Electronic Payment System"]], "related_snippets": [], "updated": "2025-07-06T21:56:50+00:00"}, "json": true, "cursor": ""}}