Provider-Preventable Conditions under 447.26(c)(1) and Payment for Services Preprint

OMB No.: 0938‑XXXX

CMS Form: CMS-10364

Citation

42 CFR 447, 434, 438, and 1902(a)(4), 1902(a)(6), and 1903

4.19 Payment for Services

The Medicaid agency meets the requirements of 42 CFR Part 447, Subpart A, and sections 1902(a)(4),

1902(a)(6), and 1903 with respect to non-payment for provider-preventable conditions. The State identifies the following provider-preventable conditions for non-payment under Section 4.19 A

____ Health Care-Acquired Conditions

____ Hospital-Acquired Conditions as identified by Medicare other than Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery in pediatric and obstetric patients.

____ Other Provider-Preventable Conditions

____ Wrong surgical or other invasive procedure performed on a patient; surgical or other invasive procedure performed on the wrong body part; surgical or other invasive procedure performed on the wrong patient.

____ Additional Other Provider-Preventable Conditions identified below (please indicate the section(s) of the plan and specific service type and provider type to which the provisions will be applied. For example – 4.19(d) nursing facility services, 4.19(b) physician services) of the plan:

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-New. The time required to complete this information collection is estimated to average 7 hours per response, including the time to complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

TN No.

Supersedes Approval Date Effective Date

TN No.

CMS ID: 7982E