CMS-10398 #13 IP Template

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

13 - Attachment I -- IP Template.xlsx

GenIC #13 (Extension w/o change): Medicaid Accountability – Nursing Facility, Outpatient Hospital and Inpatient Hospital Upper Payment Limits

OMB: 0938-1148

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1148 can be found here:

Document [xlsx]

Download: xlsx | pdf

Overview

Disclosure
Overview & Instructions
Data Dictionary
IP Cost
IP Payment
IP DRG
IP Per Diem

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 #13). 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 Inpatient UPL Template. Use the arrow keys to read through the document.

Overview
States are required to demonstrate, and Centers for Medicare and Medicaid Services (CMS) has accepted a reasonable estimate of the Upper Payment Limit (UPL) based on a comparison of Medicaid (MCD) payments to equivalent Medicare (MCR) payment or Medicaid cost using Medicare principles. 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 UPL requirements and increase comparability across states. This workbook contains templates for the inpatient hospital UPL demonstrations.

For each facility, please complete one of the following templates:
- IP Cost for cost-based demonstrations (e.g., cost-to-charge ratio x Medicaid covered IP charges)
- IP Payment for payment-based demonstrations (e.g., payment-to-charge ratio X Medicaid covered IP charges)
- IP DRG for MCR Diagnosis-Related Group (DRG)-based demonstrations (acuity adjusted price-based demonstration)
- IP Per Diem for alternative methodologies (e.g., per diem)

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:
Within each inpatient UPL template, CMS requests the following information for each inpatient hospital:
- Demonstration Information asks for basic information such as the state, demonstration rate year, service type (inpatient), and demonstration type (cost, payment, DRG, Per Diem)
- Provider Identification asks for provider identification numbers and names for each facility included, the ownership category type (private, non-state government owned, state-government owned), and whether the hospital is a critical access hospital
- Medicare Cost and Charge Data for Base Period asks for Medicare base year data relevant to the calculation of the UPL
- Medicaid (Charge and) Payment Data for Base Period asks for Medicaid charge data (for cost-based and payment-based demonstrations) or Medicaid discharge and case mix adjustment data (for DRG-based demonstrations) 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
- Medicaid Payments Inflated to Demonstration Year asks for inflationary or volume adjustment data that are made by the state to reflect changes in the Medicaid program that have occurred between the base and current rate year periods
- UPL Calculation & Inflation to Demonstration Year instructs the state to calculate the UPL and asks for inflationary adjustments to appropriately trend UPL data from the base to the current rate year
- Adjustments to UPL asks for other adjustments to the UPL that are not included in the UPL calculation (e.g., provider taxes for cost-based demonstrations)
- Calculation of UPL Gap instructs the state to calculate the UPL gap for each facility by subtracting (adjusted/inflated) Medicaid payments from the calculated UPL

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 hospital's data has also been entered for each template to provide guidance regarding the data requested for each column.

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. 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.

End of Worksheet

Sheet 3: Data Dictionary

This worksheet includes a data dictionary to assist in completing the Inpatient 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 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., Kentucky = KY)	0: Variables Included in All IP Templates
101	4-digit number	State Demonstration Rate Year	State demonstration rate year (e.g., 2014)	0: Variables Included in All IP Templates
102	2-character text	Service Type	Service type: IP = Inpatient	0: Variables Included in All IP Templates
104	Text	Demonstration Type (Cost, Payment, DRG, Per Diem)	Demonstration type (Cost= Cost-based; Payment= Payment-based; or DRG= MCR DRG-based; Per Diem = Per Diem-based	0: Variables Included in All IP Templates
105	Text	Other State Provider ID Number	State provider ID number that is not a MCD ID number (if applicable)	0: Variables Included in All IP Templates
106	Text	Explanation of Other Demonstration Type	Brief explanation of other demonstration type (e.g., cost per diem, payment per diem)	4: Variables Included in IP Per Diem Template But NOT Included Across All IP Templates
107	Text	State-specific Provider ID (MCD ID)	MCD ID number	0: Variables Included in All IP Templates
108	Text	Provider Name	Provider name	0: Variables Included in All IP Templates
109	10-11 digit number	National Provider ID (NPI)	National Provider Identification Number	0: Variables Included in All IP Templates
110	Text	Ownership Category Type (Private, NSGO, SGO)	Ownership category type (private= private; NSGO= non-state government owned; SGO= state government owned)	0: Variables Included in All IP Templates
112	6-digit number	MCR Certification Number (MCR ID)	MCR ID Number	0: Variables Included in All IP Templates
113	Text	Critical Access Hospital (CAH) Status (Y/N)	Y= critical access hospital; N= not a critical access hospital	0: Variables Included in All IP Templates
200.1	Date [DD/MM/YYYY]	MCR Cost Report Begin Date	MCR Cost Report begin date of MCR data provided that is used to calculate the UPL	0: Variables Included in All IP Templates
200.2	Date [DD/MM/YYYY]	MCR Cost Report End Date	MCR Cost Report end date of MCR data provided that is used to calculate the UPL	0: Variables Included in All IP Templates
202	Text	MCR Cost Report Filing Status	MCR Cost Report filing status (filed or settled)	0: Variables Included in All IP Templates
205.1	$ Amount	MCR Payments subject to CMI	Base year MCR payments used to calculate the UPL for which a case-mix index should be applied to account for acuity differences between the hospital's MCR and MCD populations	3: Variables Included in IP DRG Template But NOT Included Across All IP Templates
205.2	$ Amount	MCR Payments not subject to CMI	Base year MCR payments used to calculate the UPL for which no case-mix index should be applied because payments/costs are not impacted by differences in patient acuity between the hospital's MCR and MCD populations	3: Variables Included in IP DRG Template But NOT Included Across All IP Templates
206	Number	MCR Discharges	MCR discharges (if used to calculate the UPL)	3: Variables Included in IP DRG Template But NOT Included Across All IP Templates
207	Proportion	MCR Case Mix Index (CMI)	Average MCR Case Mix Index (CMI) for the facility (if used to calculate the UPL)	3: Variables Included in IP DRG Template But NOT Included Across All IP Templates
208	Proportion	MCR Cost-To-Charge Ratio (CCR)	Calculated as MCR Costs (Variable 203) / MCR Charges (Variable 204)	1: Variables Included in IP Cost Template But NOT Included Across All IP Templates
209	Proportion	MCR Payment-To-Charge Ratio (PTC)	Calculated as MCR Payments (Variable 205) / MCR Charges (Variable 204)	2: Variables Included in IP Payment Template But NOT Included Across All IP Templates
210	Number	MCR Days	Base year MCR days used to calculate the MCR Per Diem (Variable 211)	4: Variables Included in IP Per Diem Template But NOT Included Across All IP Templates
211	$ Amount	MCR Per Diem	Depending on other demonstration type, either a base year MCR payment per diem calculated as MCR Payments (Variable 205) / MCR Days (Variable 210) or a base year MCR cost per diem calculated as MCR Costs (Variable 203) / MCR Days (Variable 210)	4: Variables Included in IP Per Diem Template But NOT Included Across All IP Templates
300.1	Date [DD/MM/YYYY]	Time Period of MCD Charge and Payment Data - Begin Date	Beginning date of base year MCD payment and charge data (note: should match MCR Cost Report data period)	0: Variables Included in All IP Templates
300.2	Date [DD/MM/YYYY]	Time Period of MCD Charge and Payment Data - End Date	End date of base year MCD payment and charge data (note: should match MCR Cost Report data period)	0: Variables Included in All IP Templates
302	$ Amount	MCD Regular Payments	Total MCD non-supplemental payments for base year	0: Variables Included in All IP Templates
303.1	$ Amount	MCD Supplemental Payments	Total MCD supplemental payments for base year	0: Variables Included in All IP Templates
303.2	$ Amount	MCD Supplemental Payments - GME / Training	Total MCD supplemental payments for base year (GME=Graduate Medical Education/ Training)	0: Variables Included in All IP Templates
303.3	$ Amount	MCD Supplemental Payments - Other	Total MCD supplemental payments for base year (Other)	0: Variables Included in All IP Templates
304	Number	MCD Discharges	MCD discharges	3: Variables Included in IP DRG Template But NOT Included Across All IP Templates
305	Proportion	MCD Case Mix Index (CMI)	Average MCD Case Mix Index (CMI) for the facility	3: Variables Included in IP DRG Template But NOT Included Across All IP Templates
306	$ Amount	Total MCD Payments	Sum of MCD Regular Payments (Variable 302) + Supplemental Payments for the base year (Variable 303.1 + Variable 303.2 + Variable 303.3)	0: Variables Included in All IP Templates
307	Text	MCD Inflation Factor Type	Description of MCD payment trend factor used to reflect changes in the MCD program between the base and current rate year periods (e.g., Market Basket)	0: Variables Included in All IP Templates
308	Proportion	MCD Inflation Factor	Cumulative MCD payment trend factor used to reflect changes in the MCD program between the base and current rate year periods (note: 1.00= no change) (use "mid-point to mid-point approach")	0: Variables Included in All IP Templates
309	Proportion	Other Adjustment to MCD Payments	Cumulative other adjustment (e.g., volume adjustment) factor used to reflect changes in the MCD program between the base and current rate year periods (note: 1.00= no change) (use "mid-point to mid-point approach")	0: Variables Included in All IP Templates
310	Number	MCD Days	Base year MCD days used to calculate the UPL [by multiplying by the MCR Per Diem (Variable 211)]	4: Variables Included in IP Per Diem Template But NOT Included Across All IP Templates
318	$ Amount	Inflated MCD Payments to Demonstration Year	Calculated as Total MCD Payments (Variable 306) x MCD Inflation Factor (Variable 308) x Other Adjustment to MCD Payments (Variable 309)	0: Variables Included in All IP Templates
400	$ Amount	Calculated MCD UPL Amount	In IP Cost Template, calculated MCD UPL Amount: MCR Cost-To-Charge Ratio (Variable 208) * MCD Charges (Variable 301) In IP Payment Template, calculated MCD UPL Amount: MCR Payment-To-Charge Ratio (PTC) (Variable 209) * MCD Charges (Variable 301) In IP DRG Template, calculated MCD UPL Amount: ((MCR Payments subject to CMI (Variable 205.1) / MCR Discharges (Variable 206)) * (MCD Case Mix Index (Variable 305) / MCR Case Mix Index (Variable 207)) + MCR Payments not subject to CMI (Variable 205.2)) * MCD Discharges (Variable 304) In IP Per Diem Template, calculated MCD UPL Amount: MCR Per Diem (Variable 211) * MCD Days (Variable 310)	0: Variables Included in All IP Templates
401	$ Amount	MCD Provider Tax Cost	For cost-based demonstrations, MCD provider tax costs can be added to the UPL separately	1: Variables Included in IP Cost Template But NOT Included Across All IP Templates
402	$ Amount	Other Adjustments to the UPL Amount	Adjustments made to the UPL that are not otherwise accounted for in the UPL calculation (e.g., adjustments for managed care transition)	0: Variables Included in All IP Templates
403	$ Amount	Adjusted MCD UPL Amount	Calculated as Inflated UPL Amount (Variable 406) + Other Adjustments to the UPL Amount (Variable 402) [+ MCD Provider Tax Cost (Variable 401) for cost-based demonstrations]	0: Variables Included in All IP Templates
404	Text	UPL Inflation Factor Type	Description of payment/cost trend factor used to inflate the Calculated MCD UPL Amount (Variable 400) from the base year to the rate year (e.g., Market Basket)	0: Variables Included in All IP Templates
405	Proportion	UPL Inflation Factor	Cumulative payment/cost trend factor used to inflate the Calculated MCD UPL Amount (Variable 400) from the base year to the rate year (note: 1.00= no change) (use "mid-point to mid-point approach")	0: Variables Included in All IP Templates
406	$ Amount	Inflated UPL Amount	Calculated as Calculated MCD UPL Amount (Variable 400) x UPL Inflation Factor (Variable 405)	0: Variables Included in All IP Templates
407	$ Amount	UPL Gap Amount	Calculated as Adjusted MCD UPL Amount (Variable 403) - Inflated MCD Payments to Demonstration Year (Variable 318)	0: Variables Included in All IP Templates
408	$ Amount	Adjustment to the UPL Gap	Adjustments made to the UPL gap that are not otherwise accounted for in MCD payments or the UPL calculation	0: Variables Included in All IP Templates
409	$ Amount	Adjusted UPL Gap	Calculated as UPL Gap Amount (Variable 407) + Adjustment to the UPL Gap (Variable 408)	0: Variables Included in All IP Templates
203	$ Amount	MCR Costs	In IP Cost Template, base year MCR costs used to calculate the MCR Cost-to-Charge Ratio (CCR) (Variable 208) In IP Per Diem Template, base year MCR costs used to calculate the MCR Per Diem (Variable 211), if applicable	5: Variables Included in IP Cost and IP Per Diem Templates But NOT Included in IP Payment or IP DRG Templates
204	$ Amount	MCR Charges	In IP Cost Template, base year MCR charges used to calculate the MCR Cost-to-Charge Ratio (CCR) (Variable 208) In IP Payment Template, base year MCR charges used to calculate the MCR Payment-to-Charge Ratio (PTC) (Variable 209); if net MCR payments are used state should ensure appropriate matching to MCR charges	5: Variables Included in IP Cost and IP Payment Templates But NOT Included in IP DRG or IP Per Diem Templates
205	$ Amount	MCR Payments	In IP Payment Template, base year MCR payments used to calculate the MCR PTC (Variable 209); state should ensure appropriate matching to MCR charges (gross payments to gross charges or net payments to net charges) In IP Per Diem Template, base year MCR payments used to calculate the MCR Per Diem (Variable 211), if applicable	5: Variables Included in IP Payment and IP Per Diem Templates But NOT Included in IP Cost or IP DRG Templates
301	$ Amount	MCD Charges	In IP Cost Template, base year MCD charges, which are applied to the MCR CCR (Variable 208) to derive the Calculated MCD UPL Amount (Variable 400) In IP Payment Template, base year MCD charges, which are multiplied by the MCR PTC (Variable 209) to derive the Calculated MCD UPL Amount (Variable 400)	5: Variables Included in IP Cost and IP Payment Template But NOT Included in IP DRG or IP Diem Templates
End of Worksheet

Sheet 4: IP Cost

This worksheet includes the template for completing Inpatient 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 IP Cost 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]

Provider Info:

Ownership Category Type

[110]

Provider Info:

Critical Access Hospital Status

[113]

MCR Cost Charge Info:

Medicare Cost Report Begin Date

[200.1]

MCR Cost Charge Info:

Medicare Cost Report End Date

[200.2]

MCR Cost Charge Info:

Medicare Cost Report Filing Status

[202]

MCR Cost Charge Info:

Medicare Costs

[203]

MCR Cost Charge Info:

Medicare Charges

[204]

MCR Cost Charge Info:

Medicare Cost-To-Charge Ratio

[208]

MCD Charge and Payment Info:

Time Period of Medicaid Charge and Payment Data - Begin Date

[300.1]

MCD Charge and Payment Info:

Time Period of Medicaid Charge and Payment Data - End Date

[300.2]

MCD Charge and Payment Info:

Medicaid Charges

[301]

MCD Charge and Payment Info:

Medicaid Regular Payments

[302]

MCD Charge and Payment Info:

Medicaid Supplemental Payments

[303.1]

MCD Charge and Payment Info:

Medicaid Supplemental Payments (GME/Training)

[303.2]

MCD Charge and Payment Info:

Medicaid Supplemental Payments (Other)

[303.3]

MCD Charge and Payment Info:

Total Medicaid Payments

[306]

MCD Inflated Payment Info:

MCD Inflation Factor Type

[307]

MCD Inflated Payment Info:

MCD Inflation Factor

[308]

MCD Inflated Payment Info:

Other Adjustment to Medicaid Payments

[309]

MCD Inflated Payment Info:

Inflated Medicaid Payments to Demonstration Year

[318]

UPL Calc Info:

Calculated Medicaid UPL Amount

[400]

UPL Calc Info:

UPL Inflation Factor Type

[404]

UPL Calc Info:

UPL Inflation Factor

[405]

UPL Calc Info:

Inflated UPL Amount

[406]

UPL Adjustment Info:

Medicaid Provider Tax Cost

[401]

UPL Adjustment Info:

Other Adjustments to the UPL Amount

[402]

UPL Adjustment Info:

Adjusted Medicaid UPL Amount

[403]

UPL Gap Info:

UPL Gap Amount

[407]

UPL Gap Info:

Adjustment to the UPL Gap

[408]

UPL Gap Info:

Adjusted UPL Gap

[409]

EXAMPLE

2015

Cost

A123456

1234567890

180000

34035324

EXAMPLE HOSPITAL

Private

7/1/2012

6/30/2013

Filed

$5,000,000

$10,000,000

50.00%

7/1/2012

6/30/2013

$12,000,000

$4,000,000

$250,000

$125,000

$4,500,000

None

1.000

1.030

$4,635,000

$6,000,000

Market Basket

1.055

$6,328,350

$200,000

$6,528,350

$1,893,350

No Data

End of Worksheet

Sheet 5: IP Payment

This worksheet includes the template for completing Inpatient 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 IP Payment 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]

Provider Info:

Ownership Category Type

[110]

Provider Info:

Critical Access Hospital Status

[113]

MCR Cost Charge Info:

Medicare Cost Report Begin Date

[200.1]

MCR Cost Charge Info:

Medicare Cost Report End Date

[200.2]

MCR Cost Charge Info:

Medicare Cost Report Filing Status

[202]

MCR Cost Charge Info:

Medicare Payments

[205]

MCR Cost Charge Info:

Medicare Charges

[204]

MCR Cost Charge Info:

Medicare Payment-To-Charge Ratio

[209]

MCD Charge and Payment Info:

Time Period of Medicaid Charge and Payment Data - Begin Date

[300.1]

MCD Charge and Payment Info:

Time Period of Medicaid Charge and Payment Data - End Date

[300.2]

MCD Charge and Payment Info:

Medicaid Charges

[301]

MCD Charge and Payment Info:

Medicaid Regular Payments

[302]

MCD Charge and Payment Info:

Medicaid Supplemental Payments

[303.1]

MCD Charge and Payment Info:

Medicaid Supplemental Payments
(GME/Training)

[303.2]

MCD Charge and Payment Info:

Medicaid Supplemental Payments (Other)

[303.3]

MCD Charge and Payment Info:

Total Medicaid Payments

[306]

MCD Inflated Payment Info:

MCD Inflation Factor Type

[307]

MCD Inflated Payment Info:

MCD Inflation Factor

[308]

MCD Inflated Payment Info:

Other Adjustment to Medicaid Payments

[309]

MCD Inflated Payment Info:

Inflated Medicaid Payments to Demonstration Year

[318]

UPL Calc Info:

Calculated Medicaid UPL Amount

[400]

UPL Calc Info:

UPL Inflation Factor Type

[404]

UPL Calc Info:

UPL Inflation Factor

[405]

UPL Calc Info:

Inflated UPL Amount

[406]

UPL Adjustment Info:

Other Adjustments to the UPL Amount

[402]

UPL Adjustment Info:

Adjusted Medicaid UPL Amount

[403]

UPL Gap Info:

UPL Gap Amount

[407]

UPL Gap Info:

Adjustment to the UPL Gap

[408]

UPL Gap Info:

Adjusted UPL Gap

[409]

EXAMPLE

2015

Payment

A654321

1234567890

180001

34035325

EXAMPLE HOSPITAL

NSGO

7/1/2013

6/30/2014

Filed

$6,000,000

$10,000,000

60.00%

7/1/2013

6/30/2014

$9,000,000

$5,000,000

$100,000

$50,000

$5,200,000

Market Basket

1.029

0.980

$5,243,784

$5,400,000

Market Basket

1.029

$5,556,600

$200,000

$5,756,600

$512,816

-$100,000

$412,816

No Data

End of Worksheet

Sheet 6: IP DRG

This worksheet includes the template for completing Inpatient 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 IP DRG 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]

Provider Info:

Ownership Category Type

[110]

Provider Info:

Critical Access Hospital Status

[113]

MCR Cost Charge Info:

Medicare Cost Report Begin Date

[200.1]

MCR Cost Charge Info:

Medicare Cost Report End Date

[200.2]

MCR Cost Charge Info:

Medicare Cost Report Filing Status

[202]

MCR Cost Charge Info:

Medicare Payments Subject to CMI

[205.1]

MCR Cost Charge Info:

Medicare Payments Not Subject to CMI

[205.2]

MCR Cost Charge Info:

Medicare Discharges

[206]

MCR Cost Charge Info:

Medicare Case Mix Index (CMI)

[207]

MCD Charge and Payment Info:

Time Period of Medicaid Discharge and Payment Data - Begin Date

[300.1]

MCD Charge and Payment Info:

Time Period of Medicaid Discharge and Payment Data - End Date

[300.2]

MCD Charge and Payment Info:

Medicaid Regular Payments

[302]

MCD Charge and Payment Info:

Medicaid Supplemental Payments

[303.1]

MCD Charge and Payment Info:

Medicaid Supplemental Payments (GME/Training)

[303.2]

MCD Charge and Payment Info:

Medicaid Supplemental Payments (Other)

[303.3]

MCD Charge and Payment Info:

Medicaid Discharges

[304]

MCD Charge and Payment Info:

Medicaid Case Mix Index (CMI)

[305]

MCD Charge and Payment Info:

Total Medicaid Payments

[306]

MCD Inflated Payment Info:

MCD Inflation Factor Type

[307]

MCD Inflated Payment Info:

MCD Inflation Factor

[308]

MCD Inflated Payment Info:

Other Adjustment to Medicaid Payments

[309]

MCD Inflated Payment Info:

Inflated Medicaid Payments to Demonstration Year

[318]

UPL Calc Info:

Calculated Medicaid UPL Amount

[400]

UPL Calc Info:

UPL Inflation Factor Type

[404]

UPL Calc Info:

UPL Inflation Factor

[405]

UPL Calc Info:

Inflated UPL Amount

[406]

UPL Adjustment Info:

Other Adjustments to the UPL Amount

[402]

UPL Adjustment Info:

Adjusted Medicaid UPL Amount

[403]

UPL Gap Info:

UPL Gap Amount

[407]

UPL Gap Info:

Adjustment to the UPL Gap

[408]

UPL Gap Info:

Adjusted UPL Gap

[409]

EXAMPLE

2015

DRG

A111111

1234567890

180002

452364

EXAMPLE HOSPITAL

SGO

7/1/2013

6/30/2014

Filed

$5,000,000

$50,000

3,145

1.17

7/1/2013

6/30/2014

$3,500,000

$50,000

$25,000

3,600

1.08

$3,600,000

None

1.000

$3,600,000

$185,283,111

Market Basket Less Productivity Adj.

1.024

$189,729,906

$186,129,906

No Data

End of Worksheet

Sheet 7: IP Per Diem

This worksheet includes the template for completing Inpatient 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 IP Other 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]

Demo Info:

Explanation of Other Demonstration Type

[106]

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]

Provider Info:

Ownership Category Type

[110]

Provider Info:

Critical Access Hospital Status

[113]

MCR Cost Charge Info:

Medicare Cost Report Begin Date

[200.1]

MCR Cost Charge Info:

Medicare Cost Report End Date

[200.2]

MCR Cost Charge Info:

Medicare Cost Report Filing Status

[202]

MCR Cost Charge Info:

Medicare Costs

[203]

MCR Cost Charge Info:

Medicare Payments

[205]

MCR Cost Charge Info:

Medicare Days

[210]

MCR Cost Charge Info:

Medicare Per Diem

[211]

MCD Charge and Payment Info:

Time Period of Medicaid Data - Begin Date

[300.1]

MCD Charge and Payment Info:

Time Period of Medicaid Data - End Date

[300.2]

MCD Charge and Payment Info:

Medicaid Regular Payments

[302]

MCD Charge and Payment Info:

Medicaid Supplemental Payments

[303.1]

MCD Charge and Payment Info:

Medicaid
Supplemental Payments (GME/Training)

[303.2]

MCD Charge and Payment Info:

Medicaid Supplemental Payments (Other)

[303.3]

MCD Charge and Payment Info:

Medicaid Days

[310]

MCD Charge and Payment Info:

Total Medicaid Payments

[306]

MCD Inflated Payment Info:

MCD Inflation Factor Type

[307]

MCD Inflated Payment Info:

MCD Inflation Factor

[308]

MCD Inflated Payment Info:

Other Adjustment to Medicaid Payments

[309]

MCD Inflated Payment Info:

Inflated Medicaid Payments to Demonstration Year
[318]

UPL Calc Info:

Calculated Medicaid UPL Amount

[400]

UPL Calc Info:

UPL Inflation Factor Type

[404]

UPL Calc Info:

UPL Inflation Factor

[405]

UPL Calc Info:

Inflated UPL Amount

[406]

UPL Adjustment Info:

Other Adjustments to the UPL Amount

[402]

UPL Adjustment Info:

Adjusted Medicaid UPL Amount

[403]

UPL Gap Info:

UPL Gap Amount

[407]

UPL Gap Info:

Adjustment to the UPL Gap

[408]

UPL Gap Info:

Adjusted UPL Gap

[409]

EXAMPLE

2015

Other

Cost Per Diem

A2485392

1234567890

181303

23542434

EXAMPLE HOSPITAL

Private

7/1/2013

6/30/2014

Filed

$2,000,000

$1,800,000

2,130

$938.97

7/1/2013

6/30/2014

$1,300,000

$100,000

$50,000

1,976

$1,500,000

None

1.000

$1,500,000

$1,855,399

Market Basket

1.029

$1,909,206

$409,206

No Data

End of Worksheet

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