Non-Payment of Provider Preventable Conditions (APA WF 23-08 & OK SPA 23-0008)

Revisions to Agency rules and the Medicaid state plan are needed to align with the Centers for Medicare and Medicaid Services (CMS) final rule regarding Section 2702 of the Affordable Care Act, which reduces or prohibits payments related to provider preventable conditions (PPCs). PPCs include Health Care Acquired Conditions (HCACs) which apply to any inpatient hospitals settings and Other-Provider Preventable Conditions (OPPCs) which apply to any health care setting. The Agency’s list of PPCs for non-payment will align with the PPCs as identified by Medicare with exceptions for pediatric and obstetric patients for Deep Vein Thrombosis (DVT)/Pulmonary Embolism (PE) following total knee replacement or hip replacement surgery. In aligning with Medicare, two additional OPPCs for Surgical Site infection following cardiac implantable electronic device (CIED) and Iatrogenic pneumothorax with venous catheterization.

Please view the circulation document here: APA WF # 23-08

Please view the draft SPA pages here: OK SPA 23-0008

Feedback may be submitted via the comment box.

Circulation Date: 4/28/23

60-day Tribal Consultation Period: 4/28/23 – 6/27/23

Tribal Consultation: 5/2/23

Comment Due Date: 5/13/23

Medical Advisory Committee (MAC) Meeting: 9/7/23

Board Meeting: 9/20/23