Outpatient Hospital Payment

Enhanced Ambulatory Patient Groups (EAPG)

The Department of Health Care Policy & Financing (the Department) implemented the Enhanced Ambulatory Patient Grouping System for October 31, 2016. Enhanced Ambulatory Patient Groups (EAPG) weight tables are provided for reference by various healthcare partners and providers. The relative weight tables are used by the Department to reimburse hospitals for outpatient services. The Department has compiled a list of Frequently Asked Questions for providers and for Health First Colorado members regarding the implementation.

EAPG Weight Tables

EAPG Hospital-Specific Base Rates

Proposed Rule Update

The Department is proposing an update to the Code of Colorado Regulations section regarding payment for Outpatient Hospital services which will authorize a decrease in the 340B discount percentage in the EAPG methodology, resulting in an increase in payment for 340B drugs calculated via EAPGs. Additionally, this update will add non-specific language to the rate-setting methodology which will allow the Department to more easily implement rate updates occurring through budget appropriations. This rule was approved by the Medical Services Board as an emergency rule effective March 11th, and will be presented to the Medical Services Board on May 11th for final adoption to make the emergency rule permanent.

Proposed Rule Update Effective March 11, 2018

For all feedback regarding this proposed rule update, please contact HCPF_Hospitalregulatory@state.co.us.

Communication 

The Department has provided progress updates via email to its hospital provider community regarding Colorado interChange claims processing and EAPG pricing. Please see below links for copies of these letters.

Billed Amount Redistribution Logic

The Department has worked with 3M on updating the “lower of” pricing logic which compares EAPG payment to line item submitted charges. This update, which will be effective October 31, 2016 and was released as part of 3M’s October 12, 2017 service pack release, will utilize the EAPG grouper to redistribute billed amounts by visit prior to the “lower of” pricing comparison between EAPG payment and line item submitted charges. This change will make payments under the EAPG methodology more in alignment with initial payment projections. See below for an attachment providing greater detail for this update.

EAPG Billed Amount Redistribution 

For any questions regarding the billed amount redistribution logic, please email HCPF_Hospitalregulatory@state.co.us.

Licensing

Hospitals will not be required to purchase the EAPG software to facilitate the implementation of EAPGs. The EAPG grouper specific to Colorado Medicaid will assign the EAPGs to the claim lines and calculate the payment within the Department’s MMIS system. Hospitals may choose to purchase the EAPG grouping software allowing them to project revenue. For sales inquiries, please contact 3M Health Information System. For access to the EAPG Definitions Manual, please see 3M's Definitions Manual Order Agreement.

Engagement Meetings

The Department will be hosting meetings to address EAPG processes monthly from 1.00pm to 3.00pm effective March 30, 2018. Attendance can be in person at 303 E 17th Avenue, Denver CO 80203 or by logging into the webinar link listed below. Prior meeting’s recordings can be found under the date of the meeting.

Webinar Link