CMS-10398 (#24) Medicaid Qualified Practitioner Services (Physician) Sta

Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

#24 -- X - UPL Physician Template.xlsx

Bundle: #13 (UPL 1), #24 (UPL 2), and #46 (1915(i) State Plan Home and Community Based Services)

OMB: 0938-1148

Document [xlsx]
Download: xlsx | pdf

Overview

Disclosure
Overview & Instructions
Data Dictionary
Physician


Sheet 1: Disclosure

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.

Sheet 2: Overview & Instructions

This worksheet is for providing an overview and instructions for the Physician UPL Template. Use the arrow keys to read through the document.
Overview
States can provide enhanced payments to physicians and practitioners that are affiliated with academic medical centers or safety net hospitals in order to ensure access to their services for Medicaid (MCD) beneficiaries. However, payments are required to be “consistent with efficiency, economy and quality of care” as determined by Average Commercial Rates (ACR). An enhanced payment can be made up to the allowed amounts (provider payment + patient cost-sharing) of the top (5) commercial payers that are subject to market forces [excludes Medicare (MCR), Worker’s Comp. and managed care plans that pay a sub-capitated amount]. Data must be derived from the eligible provider’s billing system, must be within 2 years of the ACR demonstration period, provided for each Current Procedural Terminology (CPT) code eligible for enhanced payment in SPA, and should include only professional services (i.e., technical components for radiology, lab and anesthesia are excluded). Centers for Medicare and Medicaid Services (CMS) has developed guidance documents to help states meet statutory and regulatory requirements that can be downloaded from:
http://www.medicaid.gov/medicaid-chip-program-information/by-topics/financing-and-reimbursement/accountability-guidance.html
CMS is also introducing templates specific to each service and demonstration type, which have been developed to assist states in meeting the Upper Payment Limit (UPL) requirements and increase comparability across states. This workbook contains templates for the Qualified 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 owned or operated facilities and private facilities; however, the formula should be consistently applied to each provider within the category. Additionally, each facility should only be included in one type of UPL demonstration. In filling out these templates, data for each individual provider should be included on a separate row. Additionally, all supplemental payments made by the state should be reported for each individual provider and reported separately from regular Medicaid payments. There may be instances where a variable is not applicable to your UPL calculation. 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 (physician)
- 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 System (HCPCs) codes 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 well as Medicaid payment 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 the HCPCs codes relevant 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 amount based on the state's average commercial rate or Medicare equivalent and determine the maximum supplemental payments that can be paid to the provider
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 0.1235)
Detailed descriptions for each variable are provided in the next sheet labeled "Data Dictionary." A hypothetical Clinic's data has also been entered for each template to provide guidance regarding the data requested for each column.
End of Worksheet

Sheet 3: Data Dictionary

This worksheet includes a data dictionary to assist in completing the Physician Template. The table includes the variable number, required variable format, a short description of the input variable, a longer and more detailed description of the variable, and a key for which of the template tabs the variable is used in. Use the arrow keys to read through the document.
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
Variable Number Variable Format Short Description Long Description Variable Status
100 2-character text State 2-character state ID (e.g., Connecticut = CT) 0: Variables Included in Physician Template
101 4-digit number State Demonstration Rate Year State demonstration rate year (e.g., 2014) 0: Variables Included in Physician Template
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 2-character text Service Type Service type: Physician 0: Variables Included in Physician Template
105 Unspecified Other State Provider ID Number State provider ID number that is not a MCD ID number (if applicable) 0: Variables Included in Physician Template
112 6-digit number MCR Certification Number (MCR ID) MCR ID Number 0: Variables Included in Physician Template
107 Unspecified State-specific Provider ID (MCD ID) MCD ID number 0: Variables Included in Physician Template
108 Text Provider Name Provider name 0: Variables Included in Physician Template
109 10-11 digit number National Provider ID (NPI) National Provider Identification Number 0: Variables Included in Physician Template
200.1 Date [DD/MM/YYYY] MCR Rate Period - Begin Date MCR Physician Fee Schedule begin date 0: Variables Included in Physician Template
200.2 Date [DD/MM/YYYY] MCR Rate Period - End Date MCR Physician Fee Schedule end date 0: Variables Included in Physician Template
225 $ Amount MCR Payment Amount Calculated as the practitioner's average MCR payment rate multiplied by its MCD volume 0: Variables Included in Physician Template
226 Proportion ACR as Percent of MCR Rate Provider's average commercial rate divided by its average MCR rate 0: Variables Included in Physician Template
300.1 Date [DD/MM/YYYY] Time Period of MCD Payment Data - Begin Date Beginning date of base year MCD payment data 0: Variables Included in Physician Template
300.2 Date [DD/MM/YYYY] Time Period of MCD Payment Data - End Date End date of base year MCD payment data 0: Variables Included in Physician Template
302 $ Amount MCD Regular Payments Total MCD non-supplemental payments for base year 0: Variables Included in Physician Template
304 Number MCD Volume of Services Volume of services used for computing service weighted MCD payments and enhanced payment amount 0: Variables Included in Physician Template
420.1 Date [DD/MM/YYYY] Time Period of Commercial Rate Data - Begin Date Beginning date of commercial rate data 0: Variables Included in Physician Template
420.2 Date [DD/MM/YYYY] Time Period of Commercial Rate Data - End Date End date of commercial rate data 0: Variables Included in Physician Template
422 $ Amount Average Commercial Rate (ACR) Calculated as the provider's average commercial rate multiplied by its MCD volume 0: Variables Included in Physician Template
423 $ Amount Enhanced Payment Amount 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) 0: Variables Included in Physician Template
424 $ Amount Maximum Supplemental Payments Calculate as Enhanced Payment Amount (Variable 423) - MCD Regular Payments (Variable 302) 0: Variables Included in Physician Template
End of Worksheet

Sheet 4: Physician

This worksheet includes the template for completing Physician UPL for a Costs basis. The first line of the template includes the type of information collected (for example, Provider Information), the short variable description, and the variable number. The Data Dictionary, located in Table 1 of the Data Dictionary Worksheet, can be for additional information in completing this template. The first data row of the Physician template includes examples of inputs as assistance in completing this template. Use tab to move to input areas. Use the arrow keys to read through the document.

Database Description &


Variable Number
Demo Info:


State




[100]
Demo Info:


State Demonstration Rate Year


[101]
Demo Info:


Service Type



[102]
Demo Info:


Demonstration Type



[104]
Provider Info:

Other State Provider ID Number


[105]
Provider Info:

National Provider ID (NPI)


[109]
Provider Info:


Medicare Certification Number
(Medicare ID)

[112]
Provider Info:


State-specific Provider ID (Medicaid ID)


[107]
Provider Info:


Provider Name




[108]

MCR Payment Info:

Time Period of Medicare Rates - Begin Date


[200.1]
MCR Payment Info:

Time Period of Medicare Rates - End Date


[200.2]
MCR Payment Info:

Medicare Payment Amount


[225]
MCR Payment Info:

ACR as Percent of Medicare Rate

[226]
MCD Payment and Volume Info:

Time Period of Medicaid Payment Data - Begin Date

[300.1]
MCD Payment and Volume Info:

Time Period of Medicaid Payment Data - End Date

[300.2]
MCD Payment and Volume Info:

Medicaid Regular Payments


[302]
MCD Payment and Volume Info:

Medicaid Volume of Services


[304]
Avg Commercial Rate Info:

Time Period of Commercial Rate Data - Begin Date

[420.1]
Avg Commercial Rate Info:

Time Period of Commercial Rate Data - End Date

[420.2]
Avg Commercial Rate Info:

Average Commercial Rate (ACR)


[422]
ACR Max. Supplemental Payment Info:

Enhanced Payment Amount



[423]
ACR Max. Supplemental Payment Info:

Maximum Supplemental Payments



[424]
EXAMPLE CT 2015 Physician ACR A123456 1234567980 21000 65745234 EXAMPLE PHYSICIAN GROUP 1/1/2013 12/31/2013 $21,560,636 1.34 1/1/2013 12/31/2013 $23,570,737 546,546 1/1/2013 12/31/2013 $48,354,356 $28,891,252 $5,320,515
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