CMS-10398 #24 UPL Physician Template

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

24 - X - UPL Physician Template.xlsx

GenIC #24 (Extension w/o change): Medicaid Accountability – UPL ICF/IID, Clinic Services, Medicaid Qualified Practitioner Services and Other Inpatient & Outpatient Facility Providers

OMB: 0938-1148

⚠️ Notice: This form may be outdated.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

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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

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

No Data

End Worksheet

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