Payment Calculation Update for Medicaid Outpatient Hospital Services

Community Health Plan of Washington (CHPW) is updating the grouper and weights used to calculate payments for Medicaid outpatient hospital services by prospective payment hospitals. In response to an update from the Health Care Authority, CHPW is adopting EAPG grouper version 3.11 and updated weights. An adjustment factor will be applied to the updated weights to maintain budget neutrality for HCA. The updated weights better reflect relative changes in costs for specific services. The financial impact for each hospital will depend on the hospital’s mix of services. Hospital-specific rates/EAPG conversion factors will not change.

CHPW received the updated software from our vendor and performed end to end user testing of the updated rates to ensure the new weights will be applied accurately for claims processing. CHPW will begin using the updated EAPG 3.11 version/pricing effective May 7, 2017. Outpatient facility EAPG claims processed as of May 8, 2017 will be processed with newest version V3.11.