PUB IP October2010 Out of State · 2010. 11. 26. · Title: PUB_IP_October2010_Out_of_State.xls Author: mag24 Created Date: 11/26/2010 1:45:23 PM

NEW YORK STATE DEPARTMENT OF HEALTHOFFICE OF HEALTH INSURANCE PROGRAMS

SCHEDULE OF OUT‐OF‐STATE INPATIENT DRG AND EXEMPT RATES EFFECTIVE 10/01/10 ‐ 12/31/10

Hospital Name

Rate Code 2953 (OOS Hospital

DRG)


Exempt)Rate Code 2589 (DME Add‐on)

Rate Code 2950 or 2954 (ALC

RHCF)

Rate Code 2951 or 2955 (ALC Home

Care)Rate Code 2990

(Capital per Disch)

Rate Code 2991 (Capital per

Diem)

WEF/ISAF (for High Cost

Claims)

High Cost Charge

Convertors

ABBOTT NORTHWESTERN HSP MN 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ADVENTIST MED CTR OR 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642AKRON GENERAL MEDICAL CENTER 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALAMANCE REG MED CTR NC 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALBERT EINSTEIN MED CTR PA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALEGENT HLT BERGAN MERCY MED 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALEGENT HLTH IMMANUEL MED NE 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALEXIAN BROTHERS MEDICAL CENT 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALFRED I DUPONT HOSP FOR CHID 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALL CHILDRENS HOSPITAL FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALL SAINTS MEDICAL CENTER WI 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALLEGHENY GENERAL HOSPITAL PA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALLEGHENY GENERAL HOSPITAL PA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALLEGIANCE HEALTH MI 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALLE‐KISKI MEDICAL CENTER PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALTON MEM HSP 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ALTRU HOSPITAL ND 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ANDROSOGGIN VALLEY HOPS NH 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ANTELOPE VALLEY HSP CA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ARIA HEALTH‐FRANKFORD CAMPUS 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ARKANSAS CHILDRENS HOSP AR 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642AROOSTOOK MEDICAL CENTER ME 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ASPEN VALLEY HOSPITAL CO 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ATHENS REG MED TN 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ATLANTA MEDICAL CENTER GA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ATLANTIC GEN HSP MD 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ATLANTICARE MEDICAL CTR 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ATLANTICARE REG MED CTR CITY 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ATMORE COMM HSP AL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642AUGUSTA MEDICAL CENTER VA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642AURORA SINAI MED CTR WI 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642AVENTURA HOSP & MED CTR FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642AVERA MCKENNAN HOSP&UNIV HLTH 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BALTIMORE WASHINGTON MEDICAL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BANNER BAYWOOD MED CTR AZ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BANNER DEL E WEBB MEM HSP AZ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BANNER DESERT MED CTR AZ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BANNER ESTRELLA MED CTR AZ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642

1 of 26



Hospital Name


DRG)




RHCF)


Care)Rate Code 2990

(Capital per Disch)


Diem)


Claims)

High Cost Charge

Convertors

BANNER GOOD SAMARITAN MED AZ 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BANNER HEART HOSPITAL AZ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BANNER MESA MED CTR AZ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BANNER THUNDERBIRD MED CTR AZ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAPTIST HOSPITAL FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAPTIST MEM HOSP DESOTO MS 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAPTIST MEM HOSP FOR WOMEN TN 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAPTIST MEM HOSP NORTH MS 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAPTIST MEM HOSP OF MEMPHIS 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAPTIST ST ANTHONYS MEM HOSP 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BARBERTON CITIZENS HOSP OH 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BARNES JEWISH HSP MO 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BARNES‐KASSON COUNTY HSP 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BARTON MEMORIAL HOSPITAL CA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAY MEDICAL CTR FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAYHEALTH KENT GEN HSP DE 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAYLOR MED CTR GARLAND TX 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAYLOR MED CTR GRAPE VINE TX 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAYLOR UNIVERSITY MED CTR TX 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BAYONNE MEDICAL CENTER NJ 6,736.14$ ‐$ ‐$ 261.20$ 261.20$ 638.30$ 127.53$ 1.0684 0.379209BAYSHORE COMMUNITY HOSPITAL 6,736.14$ ‐$ ‐$ 261.20$ 261.20$ 638.30$ 127.53$ 1.0684 0.379209BAYSTATE MEDICAL CENTER MA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BEEBE MEDICAL CENTER DE 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BERGEN PINES COUNTY HSP NJ 8,109.64$ ‐$ 1,295.15$ 261.20$ 261.20$ 638.30$ 127.53$ 1.0684 0.379209BERKSHIRE MEDICAL CTR MA INC 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BERT FISH MEDICAL CENTER FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BETH ISRAEL DEACONESS BOSTON 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BETHESDA HSP NORTH OH 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BETHESDA MEMORIAL HOSPITAL FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BETSY JOHNSON REG HOSP NC 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BEVERLY HSP MA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BLAKE MEDICAL CENTER FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BLOOMINGTON HSP IN 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BLOOMSBURG HOSPITAL PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BLUE RIDGE HOSP NC 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BOCA RATON COMM HOSP FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BON SECOURS DEPAUL MED CTR VA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BON SECOURS MEM REG VA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642

2 of 26



Hospital Name


DRG)




RHCF)


Care)Rate Code 2990

(Capital per Disch)


Diem)


Claims)

High Cost Charge

Convertors

BON SECOURS RICHMOND COMM VA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BORGESS MEDICAL CENTER MI 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BOSTON MEDICAL CENTER MA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BOTSFORD HOSPITAL MI 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BOZEMAN DEACONESS HOSP MT 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BRACKENRIDGE HSP TX 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BRADFORD REGIONAL MED CTR PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BRANDON HOSPITAL FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BRATTLEBORO MEM HOSPITAL VT 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BRIDGEPORT HOSPITAL 8,109.64$ ‐$ 1,295.15$ 261.20$ 261.20$ 638.30$ 127.53$ 1.0684 0.379209BRIGHAM AND WOMENS HOSP 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BRISTOL HOSPITAL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BROADLAWNS MEDICAL CENTER IA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BROCKTON HOSP MA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BROMENN REG MED CTR IL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BRONSON METHODIST HOSP MI 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BROOKEGLEN BEHAVIORAL HOSPITA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BROOKWOOD MED CTR AL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BROWARD GENERAL MEDICAL CTR 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BRYANLGH MED CTR EAST NE 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BRYN MAWR HOSPITAL PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642BRYN MAWR REHAB HOSP. PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CAMBRIDGE MEDICAL CENTER MN 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CAMDEN CLARK MEMORIAL HOSP WV 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CANDLER HOSP GA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CAPE CANAVERAL HOSP FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CAPE CORAL HSP FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CAPE REGIONAL MEDICAL CENTER 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CAPITAL HEALTH SYS AT FULD 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CAPITAL HEALTH SYSTEM MERCER 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CARILION FRANKLIN MEMORIAL VA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CARILION ROANOKE COMM HSP VA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CARILION ROANOKE MEMORIAL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CARILION STONEWALL JACKSN VA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CARITAS CARNE HSP MA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CARITAS GOOD SAMARITAN MED CT 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CARITAS NORWOOD HOSP MA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CAROLINAEAST HEALTH SYSTEM 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642

3 of 26



Hospital Name


DRG)




RHCF)


Care)Rate Code 2990

(Capital per Disch)


Diem)


Claims)

High Cost Charge

Convertors

CAROLINAS MEDICAL CENTER NC 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CAROLINAS MEDICAL CENTER NORT 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CAROLINAS MEDICAL CTR UNION N 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CARONDELET ST JOSEPHS HSP AZ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CARONDELET ST MARYS HOSP AZ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CARROLL HOSPITAL CENTER MD 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CASA GRANDE REG MED CTR AZ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CASTLE MEDICAL CENTER HI 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CASTLEVIEW HOSPITAL UT 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CATHOLIC HTHCRE WEST(ST ROSE) 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CEDARS MEDICAL CENTER FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CENTENNIAL HILLS HOSP MED CTR 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CENTENNIAL MED CTR TN 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CENTENNIAL MEDICAL CENTER TX 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CENTRAL BAPTIST HOSPITAL KY 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CENTRAL CAROLINA HOSPITAL NC 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CENTRAL FLORIDA REG HOSP 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CENTRAL MONTGOMERY MC PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CENTRAL PENINSULA GEN AK 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CENTRAL VERMONT HOSPITAL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CENTRASTATE MED CTR NJ 8,109.64$ ‐$ 1,295.15$ 261.20$ 261.20$ 638.30$ 127.53$ 1.0684 0.379209CENTURA PENROSE ST FRANCIS HL 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHAMBERSBURG HOSPITAL PA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHARLES COLE MEMORIAL HSP 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHARLESTON AREA MED CTR WV 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHARLOTTE HUNGERFORD HOSPITAL 6,736.14$ ‐$ ‐$ 261.20$ 261.20$ 638.30$ 127.53$ 1.0684 0.379209CHARLOTTE REGIONAL MC FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHESAPEAKE GENERAL HOSP VA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHESTER COUNTY HOSP PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOME OF PITTSBURGH 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSP LA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSP & RESEARCH CA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSP M C OH 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSP MED CTR OH 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSP OF MI 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSP OF PHILA PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSP OF WI 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSPITAL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642

4 of 26



Hospital Name


DRG)




RHCF)


Care)Rate Code 2990

(Capital per Disch)


Diem)


Claims)

High Cost Charge

Convertors

CHILDRENS HOSPITAL CO 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSPITAL ALABAMA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSPITAL CENTRAL CA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSPITAL OF PITTS 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HOSPITAL OH 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HSP KINGS DAUGHTER 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS HSP REG MED CTR WA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS INSTITUTE OF PITTS 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS MEDICAL CENTER OH 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS MEM HSP IL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDREN'S NATIONAL MED CTR 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHILDRENS SPECIALIZED HOSP NJ ‐$ 1,534.29$ ‐$ 261.20$ 261.20$ ‐$ ‐$ 1.0684 0.379209CHILTON MEM HOSP NJ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHIPPENHAM JOHNSTON WILLIS V 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHOWAN HOSPITAL NC INC 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHRIST HOSPITAL NJ 8,109.64$ ‐$ 1,295.15$ 261.20$ 261.20$ 638.30$ 127.53$ 1.0684 0.379209CHRIST HSP & MED CTR IL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHRISTIAN HOSP NORTHEAST MO 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHRISTIANA CARE HLTH SERV DE 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CHRISTUS HLTH NORTHERN LOUISI 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CITRUS MEMORIAL HOSPITAL FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CITY HOSPITAL WV 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CLARA MAASS MEM HOSP 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CLARION HOSPITAL PA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CLARION PSYCHIATRIC CTR PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CLEVELAND CLINIC FOUNDATION 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CLEVELAND CLINIC HOSPITAL FL 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CMC PINEVILLE HOSPITAL NC 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COATESVILLE HOSPITAL PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COLLETON MEDICAL CENTER SC 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COLUMBIA DOCTORS HSP FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COLUMBIA HENRICO DOCTORS VA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COLUMBIA HSP FL 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COLUMBIA WESLEY MEDICAL CENTE 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COMMUNITY HLTH CTR BRANCH CTY 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COMMUNITY HOSPITAL ASSOCIATIO 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COMMUNITY HOSPITALS IN 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COMMUNITY HSP OF OTTAWA IL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642

5 of 26



Hospital Name


DRG)




RHCF)


Care)Rate Code 2990

(Capital per Disch)


Diem)


Claims)

High Cost Charge

Convertors

COMMUNITY MED CTR NJ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COMMUNITY MEDICAL CENTER PA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COMMUNITY MEMORIAL HOSP VA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COMMUNITY REGIONAL MEDICAL CN 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CONCORD HOSPITAL NH 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CONEMAUGH VALLEY MEM HSP PA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CONNECTICUT CHILDRENS MED CTR 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CONTRA COSTA REG MED CTR CA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CONWAY HOSPITAL SC 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COOKEVILLE REG MED CTR TN 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COOLEY DICKINSON HOSP MA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COOPER MED CTR CAMDEN NJ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COPLEY HOSPITAL VT INC 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CORAL GABLES HOSPITAL FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CORAL SPRINGS MEDICAL CTR FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CORRY MEMORIAL HOSPITAL PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642COSHOCTON CO MEM HOSPITAL OH 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CREIGHTON UNIV MED CTR NE 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CRESTWOOD MEDICAL CENTER AL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CROZER‐CHESTER MEDICAL CTR PA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CULPEPER MEM HOSP VA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CUMBERLAND HOSP VA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CUSHING MEMORIAL HOSPITAL KS 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642CYPRESS FAIRBANKS M C TX 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DANA FARBER CANCER INSTITUTE 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DANBURY HOSP CT 8,109.64$ ‐$ 1,295.15$ 261.20$ 261.20$ 638.30$ 127.53$ 1.0684 0.379209DAVIS MEMORIAL HOSPITAL WV 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DAY KIMBALL HOSPITAL CT 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DEBORAH HEART AND LUNG CTR 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DEL SOL MEDICAL CENTER TX 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DELAWARE CTY MEMORIAL HSP PA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DELTA CTY MEM HSP CO 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DESERT REG MED CTR CA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DESERT SPRINGS HOSP NV 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DETROIT RECEIVING HSP MI 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DIXIE MEDICAL CENTER UT 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DOCTORS COMMUNITY HOSPITAL MD 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DOCTORS HOSP OF AUGUSTA GA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642

6 of 26



Hospital Name


DRG)




RHCF)


Care)Rate Code 2990

(Capital per Disch)


Diem)


Claims)

High Cost Charge

Convertors

DOCTORS HOSPITAL TX 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DOCTORS MEDICAL CNTR MODES CA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DOYLESTOWN HOSPITAL PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DUBOIS REG MED CTR MERCY DIV 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DUKE RALEIGH HOSPITAL NC 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DUKE UNIVERSITY HOSPITAL NC 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642DURHAM REGIONAL HOSPITAL NC 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EAST GEORGIA REG MED CTR 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EAST JEFFERSON GEN HOSP LA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EAST ORANGE GENERAL HOSPITAL 6,736.14$ ‐$ ‐$ 261.20$ 261.20$ 638.30$ 127.53$ 1.0684 0.379209EAST TENNESSE CHILD HOSP 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EASTERN IDAHO REG MED CTR ID 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EASTERN NEW MEXICO MED NM 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EASTON HOSPITAL PA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EDWARD W SPARROW HSP MI 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EDWARD WHITE HOSPITAL FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EHS TRINITY HOSP IL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ELIZA COFFEE MEMORIAL HOSP AL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ELLIOT HOSPITAL NH 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ELMORE MEDICAL CTR ID 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EMMA PENDLETON BRADLEY HSP RI 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EMORY ADVENTIST HOSP GA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EMORY UNIVERSITY HSP GA 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ENGLEWOOD COMM HOSP FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642ENGLEWOOD HOSP MED CTR NJ 8,109.64$ ‐$ 1,295.15$ 261.20$ 261.20$ 638.30$ 127.53$ 1.0684 0.379209EPHRATA COMMUNITY HOSPITAL PA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EXEMPLA LUTHERAN MED CTR CO 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642EXEMPLA ST JOSEPH HOSPITAL 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FAIRBANKS MEM HSP AK 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FAIRFAX HOSPITAL VA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FAIRMONT GEN HSP WV 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FAIRVIEW GENERAL HOSPITAL OH 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FAIRVIEW HOSPITAL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FAIRVIEW NORTHLAND REG HSP MN 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FAIRVIEW PARK HOSPITAL GA 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FAIRVIEW UNIV MED CTR MN 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FAWCETT MEMORIAL HOSPITAL FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FAYETTE COUNTY HOSPITAL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642

7 of 26



Hospital Name


DRG)




RHCF)


Care)Rate Code 2990

(Capital per Disch)


Diem)


Claims)

High Cost Charge

Convertors

FIRELANDS REG MED CTR OH 5,917.25$ ‐$ 298.23$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FIRST HEALTH OF CAROLINAS NC 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FLAGLER HOSPITAL FL 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ 427.24$ 89.13$ 0.8424 0.476642FLAGSTAFF HOSP AND MED CTR AZ 5,311.24$ ‐$ ‐$ 171.74$ 171.74$ �

Documents

PUB IP October2010 Out of State · 2010. 11. 26. · Title: PUB_IP_October2010_Out_of_State.xls Author: mag24 Created Date: 11/26/2010 1:45:23 PM