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UPL Physician
ICR 201410-0938-016 · OMB 0938-1148 · Object 69422001.
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| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
|---|---|
| File Title | UPL Physician |
| Subject | UPL Physician |
| Author | CMS |
| Last Modified By | Calc |
| File Modified | 2016-11-10 |
| File Created | 2026-08-26 |
| Conversion State | complete |
Extracted Text
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 0938-1148 (CMS-10398 #24). The time required to complete this information collection is estimated to average 40 per response, including the time to review instructions, search existing data resources, gather the data needed, and 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. Inpatient Hospital Upper Payment Limit (UPL) Data Template Overview States can provide enhanced payments to physicians and practitioners that are affiliated with academic medical cen hospitals in order to ensure access to their services for Medicaid (MCD) beneficiaries. However, payments are requi efficiency, economy and quality of care” as determined by Average Commercial Rates (ACR). An enhanced payment allowed amounts (provider payment + patient cost-sharing) of the top (5) commercial payers that are subject to ma Medicare (MCR), Worker’s Comp. and managed care plans that pay a sub-capitated amount]. Data must be derived provider’s billing system, must be within 2 years of the ACR demonstration period, provided for each Current Proced code eligible for enhanced payment in SPA, and should include only professional services (i.e., technical component anesthesia are excluded). Centers for Medicare and Medicaid Services (CMS) has developed guidance documents to statutory and regulatory requirements that can be downloaded from: http://www.medicaid.gov/medicaid-chip-program-information/by-topics/financing-and-reimbursement/accountab CMS is also introducing templates specific to each service and demonstration type, which have been developed to a Upper Payment Limit (UPL) requirements and increase comparability across states. This workbook contains templat Practitioner Services Average Commercial Rate (ACR) UPL demonstrations. For each applicable provider, please complete the attached ACR template. States may apply different UPL formulas for state government owned or operated facilities, non-state government o facilities and private facilities; however, the formula should be consistently applied to each provider within the cate facility should only be included in one type of UPL demonstration. In filling out these templates, data for each indiv included on a separate row. Additionally, all supplemental payments made by the state should be reported for ea and reported separately from regular Medicaid payments. There may be instances where a variable is not applicab Please leave these variables blank. Information Requested: CMS requests the following information for each qualified practitioner: - Demonstration Information asks for basic information such as the state, demonstration rate year, and service type - Provider Identification asks for provider identification numbers and names for each provider included - Medicare Payment Data asks for base year Medicare payment rates for Healthcare Common Procedure Coding Sy relevant to the ACR demonstration and multiplied by the corresponding Medicaid service volume - Medicaid Payment and Volume Data for Base Period asks for Medicaid volume data used to calculate the UPL, as data that is used to determine whether or not the state has made payments in excess of the UPL - Average Commercial Rate Data asks for data on the average payment rates for the top 5 commercial insurers for t to the ACR demonstration and multiplied by the corresponding Medicaid service volumes - ACR and Maximum Supplemental Payment Calculation asks for the state to calculate the enhanced payment amo average commercial rate or Medicare equivalent and determine the maximum supplemental payments that can be Payment and Cost Data: Enter to the nearest dollar (i.e. $1,234,567.89 should be entered as $1,234,568) Proportion and Percentage Data: Enter with no more than four decimal places (i.e., 0.12345 should be entered as 0 source.xlsx Overview and Instructions 2 Inpatient Hospital Upper Payment Limit (UPL) Data Template Detailed descriptions for each variable are provided in the next sheet labeled "Data Dictionary." A hypothetical C entered for each template to provide guidance regarding the data requested for each column. source.xlsx Overview and Instructions 3 Inpatient Hospital Upper Payment Limit (UPL) Data Template Variable Number 100 101 Variable Format 2-character text 4-digit number Table 1. CMS Physician UPL Template Data Dictionary Variable numbering scheme is used for internal identification of each variable and is not meant to be presented in numerical order Short Description Long Description State 2-character state ID (e.g., Connecticut = CT) State Demonstration Rate Year State demonstration rate year (e.g., 2014) 104 Text Demonstration Type (ACR, MCR Equivalent) Demonstration type (ACR = Average Commercial Rate; MCR Equivalent = MCR Equivalent Payment 0: Variables Included in Physician Template 102 105 112 107 108 109 200.1 200.2 225 226 300.1 300.2 302 2-character text Unspecified 6-digit number Unspecified Text 10-11 digit number Date [DD/MM/YYYY] Date [DD/MM/YYYY] $ Amount Proportion Date [DD/MM/YYYY] Date [DD/MM/YYYY] $ Amount Service Type Other State Provider ID Number MCR Certification Number (MCR ID) State-specific Provider ID (MCD ID) Provider Name National Provider ID (NPI) MCR Rate Period - Begin Date MCR Rate Period - End Date MCR Payment Amount ACR as Percent of MCR Rate Time Period of MCD Payment Data - Begin Date Time Period of MCD Payment Data - End Date MCD Regular Payments 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 304 Number MCD Volume of Services 420.1 420.2 422 Date [DD/MM/YYYY] Date [DD/MM/YYYY] $ Amount Time Period of Commercial Rate Data - Begin Date Time Period of Commercial Rate Data - End Date Average Commercial Rate (ACR) 423 $ Amount Enhanced Payment Amount Service type: Physician State provider ID number that is not a MCD ID number (if applicable) MCR ID Number MCD ID number Provider name National Provider Identification Number MCR Physician Fee Schedule begin date MCR Physician Fee Schedule end date Calculated as the practitioner's average MCR payment rate multiplied by its MCD volume Provider's average commercial rate divided by its average MCR rate Beginning date of base year MCD payment data End date of base year MCD payment data Total MCD non-supplemental payments for base year Volume of services used for computing service weighted MCD payments and enhanced payment amount Beginning date of commercial rate data End date of commercial rate data Calculated as the provider's average commercial rate multiplied by its MCD volume If using the ACR approach - set equal to Average Commercial Rate (Variable 422); If using the MCR equivalent approach calculate as MCR Payment Amount (Variable 225) x ACR as Percent of MCR Rate (Variable 226) 424 $ Amount Maximum Supplemental Payments Calculate as Enhanced Payment Amount (Variable 423) - MCD Regular Payments (Variable 302) 0: Variables Included in Physician Template Data Dictionary Variable Status 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 0: Variables Included in Physician Template 4 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template A 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Database Description & Variable Number EXAMPLE B C Demo Info: Demo Info: State D Demo Info: E F G Demo Info: Provider Info: Provider Info: National State Demonstration Other State Service Type Provider ID Demonstration Type Provider ID (NPI) Rate Year Number [100] [101] CT 2015 [102] Physician [104] [105] ACR A123456 [109] 1234567980 H I J Provider Info: Provider Info: Provider Info: Medicare State-specific Certification Provider ID Number (Medicaid ID) (Medicare ID) Provider Name [112] [107] [108] 21000 65745234 EXAMPLE PHYSICIAN GROUP No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data source.xlsx ACR 5 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template A 2 3 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 Database Description & Variable Number EXAMPLE B C Demo Info: Demo Info: State D Demo Info: E F G Demo Info: Provider Info: Provider Info: National State Demonstration Other State Service Type Provider ID Demonstration Type Provider ID (NPI) Rate Year Number [100] [101] CT 2015 [102] Physician [104] [105] ACR A123456 [109] 1234567980 H I J Provider Info: Provider Info: Provider Info: Medicare State-specific Certification Provider ID Number (Medicaid ID) (Medicare ID) Provider Name [112] [107] [108] 21000 65745234 EXAMPLE PHYSICIAN GROUP No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data source.xlsx ACR 6 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template A 2 3 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 Database Description & Variable Number EXAMPLE B C Demo Info: Demo Info: State D Demo Info: E F G Demo Info: Provider Info: Provider Info: National State Demonstration Other State Service Type Provider ID Demonstration Type Provider ID (NPI) Rate Year Number [100] [101] CT 2015 [102] Physician [104] [105] ACR A123456 [109] 1234567980 H I J Provider Info: Provider Info: Provider Info: Medicare State-specific Certification Provider ID Number (Medicaid ID) (Medicare ID) Provider Name [112] [107] [108] 21000 65745234 EXAMPLE PHYSICIAN GROUP No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data source.xlsx ACR 7 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template A 2 3 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 Database Description & Variable Number EXAMPLE B C Demo Info: Demo Info: State D Demo Info: E F G Demo Info: Provider Info: Provider Info: National State Demonstration Other State Service Type Provider ID Demonstration Type Provider ID (NPI) Rate Year Number [100] [101] CT 2015 [102] Physician [104] [105] ACR A123456 [109] 1234567980 H I J Provider Info: Provider Info: Provider Info: Medicare State-specific Certification Provider ID Number (Medicaid ID) (Medicare ID) Provider Name [112] [107] [108] 21000 65745234 EXAMPLE PHYSICIAN GROUP No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data source.xlsx ACR 8 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template A 2 3 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 Database Description & Variable Number EXAMPLE B C Demo Info: Demo Info: State D Demo Info: E F G Demo Info: Provider Info: Provider Info: National State Demonstration Other State Service Type Provider ID Demonstration Type Provider ID (NPI) Rate Year Number [100] [101] CT 2015 [102] Physician [104] [105] ACR A123456 [109] 1234567980 H I J Provider Info: Provider Info: Provider Info: Medicare State-specific Certification Provider ID Number (Medicaid ID) (Medicare ID) Provider Name [112] [107] [108] 21000 65745234 EXAMPLE PHYSICIAN GROUP No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data source.xlsx ACR 9 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template A 2 3 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 Database Description & Variable Number EXAMPLE B C Demo Info: Demo Info: State D Demo Info: E F G Demo Info: Provider Info: Provider Info: National State Demonstration Other State Service Type Provider ID Demonstration Type Provider ID (NPI) Rate Year Number [100] [101] CT 2015 [102] Physician [104] [105] ACR A123456 [109] 1234567980 H I J Provider Info: Provider Info: Provider Info: Medicare State-specific Certification Provider ID Number (Medicaid ID) (Medicare ID) Provider Name [112] [107] [108] 21000 65745234 EXAMPLE PHYSICIAN GROUP No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data source.xlsx ACR 10 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template A 2 3 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 Database Description & Variable Number EXAMPLE B C Demo Info: Demo Info: State D Demo Info: E F G Demo Info: Provider Info: Provider Info: National State Demonstration Other State Service Type Provider ID Demonstration Type Provider ID (NPI) Rate Year Number [100] [101] CT 2015 [102] Physician [104] [105] ACR A123456 [109] 1234567980 H I J Provider Info: Provider Info: Provider Info: Medicare State-specific Certification Provider ID Number (Medicaid ID) (Medicare ID) Provider Name [112] [107] [108] 21000 65745234 EXAMPLE PHYSICIAN GROUP No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data No Data source.xlsx ACR 11 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template 2 K L MCR Payment Info: MCR Payment Info: Time Period of Time Period of Medicare Rates - Medicare Rates End Date Begin Date 3 M N O P Q R S T U V MCR Payment MCD Payment MCD Payment Avg Commercial ACR Max. Supplemental MCR Payment MCD Payment MCD Payment Avg Commercial Avg Commercial Info: and Volume Info: and Volume Info: Rate Info: Payment Info: Info: and Volume Info: and Volume Info: Rate Info: Rate Info: Medicare Payment Amount [200.1] [200.2] [225] 1/1/2013 12/31/2013 $21,560,636 Time Period of ACR as Percent Medicaid of Medicare Payment Data Rate Begin Date [226] 1.34 Time Period of Medicaid Payment Data End Date [300.1] [300.2] 1/1/2013 12/31/2013 Average Medicaid Regular Medicaid Volume Time Period of Time Period of Commercial Rate Payments of Services Commercial Rate Commercial Rate (ACR) Data - Begin Date Data - End Date [302] [304] [420.1] [420.2] $23,570,737 546,546 1/1/2013 12/31/2013 Enhanced Payment Amount [422] [423] $48,354,356 $28,891,252 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 source.xlsx ACR 12 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template 2 K L MCR Payment Info: MCR Payment Info: Time Period of Time Period of Medicare Rates - Medicare Rates End Date Begin Date 3 M N O P Q R S T U V MCR Payment MCD Payment MCD Payment Avg Commercial ACR Max. Supplemental MCR Payment MCD Payment MCD Payment Avg Commercial Avg Commercial Info: and Volume Info: and Volume Info: Rate Info: Payment Info: Info: and Volume Info: and Volume Info: Rate Info: Rate Info: Medicare Payment Amount [200.1] [200.2] [225] 1/1/2013 12/31/2013 $21,560,636 Time Period of ACR as Percent Medicaid of Medicare Payment Data Rate Begin Date [226] 1.34 Time Period of Medicaid Payment Data End Date [300.1] [300.2] 1/1/2013 12/31/2013 Average Medicaid Regular Medicaid Volume Time Period of Time Period of Commercial Rate Payments of Services Commercial Rate Commercial Rate (ACR) Data - Begin Date Data - End Date [302] [304] [420.1] [420.2] $23,570,737 546,546 1/1/2013 12/31/2013 Enhanced Payment Amount [422] [423] $48,354,356 $28,891,252 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 source.xlsx ACR 13 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template 2 K L MCR Payment Info: MCR Payment Info: Time Period of Time Period of Medicare Rates - Medicare Rates End Date Begin Date 3 M N O P Q R S T U V MCR Payment MCD Payment MCD Payment Avg Commercial ACR Max. Supplemental MCR Payment MCD Payment MCD Payment Avg Commercial Avg Commercial Info: and Volume Info: and Volume Info: Rate Info: Payment Info: Info: and Volume Info: and Volume Info: Rate Info: Rate Info: Medicare Payment Amount [200.1] [200.2] [225] 1/1/2013 12/31/2013 $21,560,636 Time Period of ACR as Percent Medicaid of Medicare Payment Data Rate Begin Date [226] 1.34 Time Period of Medicaid Payment Data End Date [300.1] [300.2] 1/1/2013 12/31/2013 Average Medicaid Regular Medicaid Volume Time Period of Time Period of Commercial Rate Payments of Services Commercial Rate Commercial Rate (ACR) Data - Begin Date Data - End Date [302] [304] [420.1] [420.2] $23,570,737 546,546 1/1/2013 12/31/2013 Enhanced Payment Amount [422] [423] $48,354,356 $28,891,252 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138 139 140 141 142 143 144 145 146 147 148 149 150 source.xlsx ACR 14 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template 2 K L MCR Payment Info: MCR Payment Info: Time Period of Time Period of Medicare Rates - Medicare Rates End Date Begin Date 3 M N O P Q R S T U V MCR Payment MCD Payment MCD Payment Avg Commercial ACR Max. Supplemental MCR Payment MCD Payment MCD Payment Avg Commercial Avg Commercial Info: and Volume Info: and Volume Info: Rate Info: Payment Info: Info: and Volume Info: and Volume Info: Rate Info: Rate Info: Medicare Payment Amount [200.1] [200.2] [225] 1/1/2013 12/31/2013 $21,560,636 Time Period of ACR as Percent Medicaid of Medicare Payment Data Rate Begin Date [226] 1.34 Time Period of Medicaid Payment Data End Date [300.1] [300.2] 1/1/2013 12/31/2013 Average Medicaid Regular Medicaid Volume Time Period of Time Period of Commercial Rate Payments of Services Commercial Rate Commercial Rate (ACR) Data - Begin Date Data - End Date [302] [304] [420.1] [420.2] $23,570,737 546,546 1/1/2013 12/31/2013 Enhanced Payment Amount [422] [423] $48,354,356 $28,891,252 151 152 153 154 155 156 157 158 159 160 161 162 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 source.xlsx ACR 15 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template 2 K L MCR Payment Info: MCR Payment Info: Time Period of Time Period of Medicare Rates - Medicare Rates End Date Begin Date 3 M N O P Q R S T U V MCR Payment MCD Payment MCD Payment Avg Commercial ACR Max. Supplemental MCR Payment MCD Payment MCD Payment Avg Commercial Avg Commercial Info: and Volume Info: and Volume Info: Rate Info: Payment Info: Info: and Volume Info: and Volume Info: Rate Info: Rate Info: Medicare Payment Amount [200.1] [200.2] [225] 1/1/2013 12/31/2013 $21,560,636 Time Period of ACR as Percent Medicaid of Medicare Payment Data Rate Begin Date [226] 1.34 Time Period of Medicaid Payment Data End Date [300.1] [300.2] 1/1/2013 12/31/2013 Average Medicaid Regular Medicaid Volume Time Period of Time Period of Commercial Rate Payments of Services Commercial Rate Commercial Rate (ACR) Data - Begin Date Data - End Date [302] [304] [420.1] [420.2] $23,570,737 546,546 1/1/2013 12/31/2013 Enhanced Payment Amount [422] [423] $48,354,356 $28,891,252 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 source.xlsx ACR 16 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template 2 K L MCR Payment Info: MCR Payment Info: Time Period of Time Period of Medicare Rates - Medicare Rates End Date Begin Date 3 M N O P Q R S T U V MCR Payment MCD Payment MCD Payment Avg Commercial ACR Max. Supplemental MCR Payment MCD Payment MCD Payment Avg Commercial Avg Commercial Info: and Volume Info: and Volume Info: Rate Info: Payment Info: Info: and Volume Info: and Volume Info: Rate Info: Rate Info: Medicare Payment Amount [200.1] [200.2] [225] 1/1/2013 12/31/2013 $21,560,636 Time Period of ACR as Percent Medicaid of Medicare Payment Data Rate Begin Date [226] 1.34 Time Period of Medicaid Payment Data End Date [300.1] [300.2] 1/1/2013 12/31/2013 Average Medicaid Regular Medicaid Volume Time Period of Time Period of Commercial Rate Payments of Services Commercial Rate Commercial Rate (ACR) Data - Begin Date Data - End Date [302] [304] [420.1] [420.2] $23,570,737 546,546 1/1/2013 12/31/2013 Enhanced Payment Amount [422] [423] $48,354,356 $28,891,252 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 source.xlsx ACR 17 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template 2 K L MCR Payment Info: MCR Payment Info: Time Period of Time Period of Medicare Rates - Medicare Rates End Date Begin Date 3 M N O P Q R S T U V MCR Payment MCD Payment MCD Payment Avg Commercial ACR Max. Supplemental MCR Payment MCD Payment MCD Payment Avg Commercial Avg Commercial Info: and Volume Info: and Volume Info: Rate Info: Payment Info: Info: and Volume Info: and Volume Info: Rate Info: Rate Info: Medicare Payment Amount [200.1] [200.2] [225] 1/1/2013 12/31/2013 $21,560,636 Time Period of ACR as Percent Medicaid of Medicare Payment Data Rate Begin Date [226] 1.34 Time Period of Medicaid Payment Data End Date [300.1] [300.2] 1/1/2013 12/31/2013 Average Medicaid Regular Medicaid Volume Time Period of Time Period of Commercial Rate Payments of Services Commercial Rate Commercial Rate (ACR) Data - Begin Date Data - End Date [302] [304] [420.1] [420.2] $23,570,737 546,546 1/1/2013 12/31/2013 Enhanced Payment Amount [422] [423] $48,354,356 $28,891,252 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 source.xlsx ACR 18 Average Commercial Rate (ACR) Upper Payment Limit (UPL) Data Template W ACR Max. Supplemental Payment Info: 2 Maximum Supplemental Payments 3 $5,320,515 [424] 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 source.xlsx ACR 19