UPL Clinic

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Upper Payment Limit Demonstration Report

1. I HEREBY CERTIFY that I have read this certification statement and that I have examined the accompanying electronically fil
demonstration
report prepared by:

(please insert the state Medicaid official (or other person who prepared this UPL d
for the report period beginning (MM/DD/YYYY):
and ending (MM/DD/YYYY):

I further certify that, to the best of my knowledge and belief, this report is true, accurate, and complete, and except as noted,
providers and Medicaid agency in accordance with applicable instructions. I further certify that I am familiar with the laws and
and that the services identified in this Upper Payment Limit demonstration report are provided in compliance with such laws a

2. I certify that the costs reported in this Upper Payment Limit demonstration represent a reasonable estimate of the amount
consistent with 45 CFR part 75 and 2 CFR part 200, with expenditure/cost data trended forward based on historical data.

3. State and/or local funds are available and will be used to pay for total computable allowable expenditures included in this s
are in accordance with all applicable federal requirements for the non-federal share of expenditures (including that the funds
by Federal law to be used to match other Federal funds, and that the federal funds received to match the claimed expenditure
Federally funded programs).

4. I understand that this information may be used as a basis for claims for federal funds, and that falsification and concealmen
civil or criminal law.

5. I certify that, to the best of my knowledge and belief, all necessary information has been provided to support the determin
used to complete the template. I certify that, to the best of my knowledge and belief, none of the calculations or formulas in t
of the template has been used for this submission.

6. I certify that, to the best of my knowledge and belief, the structure of this OMB approved and locked template has not been
guidelines and directions have been followed in completing this UPL demonstration, and the template has been completed co

7. I am the officer authorized by the relevant state government agency to submit this form and I have made a good faith effor
Electronic Signature:
Title & Contact Information:

End of Worksheet

Upper Payment Limit Demonstration Report

ertification statement and that I have examined the accompanying electronically filed and/or manually submitted Upper Payment Limit

(please insert the state Medicaid official (or other person who prepared this UPL demonstration report) Name(s), title(s), and Contact Num

wledge and belief, this report is true, accurate, and complete, and except as noted, have been prepared from the books and records of the
ce with applicable instructions. I further certify that I am familiar with the laws and regulations regarding the provision of health care servi
r Payment Limit demonstration report are provided in compliance with such laws and regulations.

pper Payment Limit demonstration represent a reasonable estimate of the amount that Medicare would pay for these Medicaid services,
rt 200, with expenditure/cost data trended forward based on historical data.

d will be used to pay for total computable allowable expenditures included in this statement, and the source(s) of such state and/or local f
requirements for the non-federal share of expenditures (including that the funds are not Federal funds in origin or are Federal funds auth
deral funds, and that the federal funds received to match the claimed expenditures will not be used to meet matching requirements unde

e used as a basis for claims for federal funds, and that falsification and concealment of a material fact may be prosecuted under federal or

e and belief, all necessary information has been provided to support the determination of the UPL amount, including supplemental materi
at, to the best of my knowledge and belief, none of the calculations or formulas in the template have been changed, and the most recent v
mission.

e and belief, the structure of this OMB approved and locked template has not been altered in any way, all applicable instructions in the
d in completing this UPL demonstration, and the template has been completed consistent with the definitions in the data dictionary.

nt state government agency to submit this form and I have made a good faith effort to ensure that all information reported is true and accu

T

This worksheet is for providing an overview and instructions for the Clinic UPL Template. Use the arrow keys to r
Overview
States are required to demonstrate, and Centers for Medicare and Medicaid Services (CMS) has accepted a reaso
Payment Limit (UPL) based on a comparison of Medicaid (MCD) payments to equivalent Medicare (MCR) payme
Medicare principles. CMS has developed guidance documents to help states meet statutory and regulatory requ
downloaded from:
CMS Accountability Guidance

CMS is also introducing templates specific to each service type, which have been developed to assist states in me
increase comparability across states. This workbook contains a template with one input tab for the Clinic UPL de

For each facility, please complete the "Required State Input – Clinic" tab. Please ensure the top section of the in
completed, which includes the state, the start date for the demonstration, and the end date for the demonstr
that there are no gaps between yearly submissions.

If a cell has a red background, critical data for that variable is missing or invalid. Once the data is filled in with va
the template will remove the red color from the cell. For details about the valid data format and valid values for
Data Dictionary tab.

States may not enter data into the tabs labeled "Clinic" and "Total_Adjusted_UPL_Gap." The template calculates
automatically based on the data entered on the input tab. They are included as a reference only.

States may use the worksheet tabs labeled "Optional_Sheet_1," "Optional_Sheet_2," etc. to include supplement
the content for the "Required State Input – Clinic" tab. These sheets are optional. If you choose to enter data in t
please provide a brief explanation of the content at the top of the worksheet.

States may apply different UPL formulas for state government owned or operated facilities, non-state governme
facilities and private facilities; however, the formula should be consistently applied to each provider within the c
facility should only be included in one type of UPL demonstration. In filling out the input tabs within this templa
provider should be included on one separate row. Additionally, all supplemental payments made by the state
individual provider and reported separately from regular Medicaid payments. There may be instances where a
your UPL calculation. Please leave these variables blank unless otherwise noted in the data dictionary.

Information Requested:
CMS requests the following information for each Clinic:
- Demonstration Information asks for basic information such as the state, demonstration rate year, and service
- Provider Information asks for provider identification numbers and names for each facility included, the owners
non-state government owned, state-government owned), the clinic type, and the service-level category (i.e., CPT
Terminology)
- Medicare Information asks for base year data relevant to the calculation of the UPL
- Medicaid Information asks for Medicaid charge data used to calculate the UPL, as well as Medicaid payment da
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 m
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 inflatio
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
- Calculation of UPL Gap instructs the state to calculate the UPL gap for each facility by subtracting (adjusted/in
from the calculated UPL
CMS has developed an instructional document for Clinic services to help states create their UPL demonstration.
downloaded from:
CMS UPL Instructions for Clinical Services

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
Detailed descriptions for each variable are provided in the next sheet labeled "Data Dictionary." A hypothetica
entered for each template to provide guidance and formulas 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 inform
OMB control number. The valid OMB control number for this information collection is 0938-1148. The time requ
information collection is estimated to average 40 hours per response, including the time to review instructions, s
resources, gather the data needed, and complete and review the information collection. If you have comments c
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn:
Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
End of Worksheet

This worksheet includes a data dictionary to assist in completing the Clinic Template. The table includes the variable numb

Variable numbering scheme is used fo
Variable Number
001
002
003
100
101
102
103-104

Variable Format
2-character text
Date [MM/DD/YYYY]
Date [MM/DD/YYYY]
2-character text
4-digit number
6-character text
N/A

105
106
107
108
109
110

Variable Designation
Required
Required
Required
Required
Required
Required
Not Applicable to this
Template (N/A)
Provide if Applicable (PIA)
N/A
Required
Required
Provide if Applicable (PIA)
Required

111

Required

Text

112

Required

6-digit number

113-115
116

N/A
N/A
Provide if Applicable (PIA) Text

117

Provide if Applicable (PIA) 10-character text

200.1

Required

Date [MM/DD/YYYY]

200.2

Required

Date [MM/DD/YYYY]

201-202
203

N/A
Required if using Cost-toCharge Ratio (CCR)

N/A
$ Amount

204

Required if using CCR or
PTC

$ Amount

205

Required if using PTC or
Fee Schedule

$ Amount

Unspecified
N/A
Unspecified
Text
10-11 digit number
Text

206-207
208

N/A
Calculated

N/A
Proportion

209-223
224

N/A
Required

N/A
Text

225-226
300.1
300.2
301

N/A
Required
Required
Required if using CCR or
PTC

N/A
Date [MM/DD/YYYY]
Date [MM/DD/YYYY]
$ Amount

302
303.1

Required
Required

$ Amount
$ Amount

303.2

Required

$ Amount

303.3

Required

$ Amount

304-305
306

N/A
Calculated

N/A
$ Amount

307

Provide if Applicable (PIA) Text

308

Required

Proportion

309

Required

Proportion

310-317

N/A

N/A

318

Calculated

$ Amount

400

Calculated

$ Amount

401
402

N/A
Required

N/A
$ Amount

403

Calculated

$ Amount

404

Provide if Applicable (PIA) Text

405

Required

Proportion

406
407

Calculated
Calculated

$ Amount
$ Amount

408

Required

$ Amount

409
410-424

Calculated
N/A

$ Amount
N/A

e Clinic Template. The table includes the variable number, required variable format, a short description of the input variable, a longer
Table 1. CMS UPL Clinic Template Data Dictionary
Variable numbering scheme is used for internal identification of each variable and is not meant to be presented in nu
Short Description
State
Demonstration Begin Date
Demonstration End Date
State
State Demonstration Rate Year
Service Type
N/A
Other State Provider ID Number
N/A
State-specific Provider ID (MCD ID)
Provider Name
National Provider ID (NPI)
Ownership Category Type (Private, NSGO, SGO)
Clinic Type

MCR Certification Number (MCR ID)

N/A
Retrospective/Prospective Demonstration

State Plan Amendment (SPA) Number
UPL Source Data Begin Date
UPL Source Data End Date
N/A
MCR or Other Costs

MCR Charges

MCR Payments

N/A
MCR Cost-To-Charge Ratio (CCR) or Payment-to-Charge Ratio (PTC)

N/A
Source of UPL or Cost Report Data (MCR ASC Rates, Physician Fee
Schedule, Cost Report, etc.)
N/A
Time Period of MCD Charge and Payment Data - Begin Date
Time Period of MCD Charge and Payment Data - End Date
MCD Charges

MCD Base Payments
MCD Supplemental Payments

MCD Supplemental Payments - GME/Training

MCD Supplemental Payments - Other

N/A
Total MCD Supplemental Payments

MCD Inflation Factor Type

MCD Inflation Factor

Other Adjustment to MCD Payments

N/A

Inflated MCD Payments to Demonstration Year

MCD UPL Amount

N/A
Other Adjustments to the UPL Amount

Adjusted MCR UPL Amount

UPL Inflation Factor Type

UPL Inflation Factor

Inflated UPL Amount
UPL Gap Amount
Adjustment to the UPL Gap

Adjusted UPL Gap
N/A
End of Worksheet

ble format, a short description of the input variable, a longer and more detailed description of the variable, and a key for which of the
PL Clinic Template Data Dictionary
cation of each variable and is not meant to be presented in numerical order
Long Description
2-character state ID (e.g., Kentucky = KY)
Start date of the State demonstration rate year
End date of the State demonstration rate year
2-character state ID (e.g., Kentucky = KY)
State demonstration rate year YYYY (e.g., 2014)
Service type: Clinic = Clinic
N/A
State provider ID number that is not a Medicaid (MCD) ID number (if applicable).
N/A
Medicaid (MCD) ID number.
Provider name
National Provider Identification Number
Ownership category type (private= private; NSGO= non-state government owned; SGO= state
government owned).
Description of Clinic Type (ASC= Ambulatory Surgery Centers, Dialysis, CMHC= Community Mental
Health Center, Medical, BHC= Behavioral Health Center, Family Planning, County Health
Department, Methadone, etc.).
Medicare (MCR) ID number.
In the instances where a facility is Not Medicare Certified (NMC), the state should enter "NMC".
N/A
An indicator that identifies the demonstration as retrospective or prospective. UPL is considered
retrospective when it is submitted on or after the start of the demonstration period, and considered
prospective if submitted prior to the start of the demonstration period.
The state plan amendment number associated with the demonstration submission. The expected
format is: 2 letter state abbreviation-##-#### (for example, OR-19-0002).
Medicare (MCR) fee schedule begin date or cost report begin date that is used to calculate the UPL.
Medicare (MCR) fee schedule end date or cost report end date that is used to calculate the UPL.
N/A
Base Year Medicare (MCR) or other costs used to calculate the UPL. Leave this blank if using either
Payment-to-Charge Ratio (PTC) or Fee Schedule.
If variable 224 has a value of "Cost to Charge Ratio," then variable 203 should be populated with
data.
Base year Medicare (MCR) charges, if using a cost-to-charge or payment-to-charge method, used to
calculate the MCR Cost-to-Charge Ratio (CCR) or Payment-to-Charge Ratio (PTC) (Variable 208).
Leave this blank if using Fee Schedule.
If variable 224 has a value of "Cost to Charge Ratio" or "Payment to Charge Ratio," then variable 204
should be populated with data.
Base year Medicare (MCR) payments calculated from MCR fee schedules. Leave this blank if using
Cost-to-Charge Ratio (CCR).
If variable 224 has a value of "Cost to Charge Ratio" or "Fee Schedule," then variable 205 should be
populated with data.

N/A
For CCR, calculated as MCR Costs (Variable 203) / MCR Charges (Variable 204)
For PTC, calculated as MCR Payments (Variable 205) / MCR Charges (Variable 204)
This field will be left blank if the source of UPL or Cost Report Data (224) has a value other than Costto-Charge (CCR) Ratio or Payment-to-Charge (PTC) Ratio.
N/A
Specify source of UPL data used to calculate the Clinic UPL (MCR ASC Rates, Physician Fee Schedule,
Cost Report, Cost-to-Charge ratio, Payment-to-Charge Ratio, etc.).
N/A
Beginning date of base year Medicaid (MCD) payment and charge data (if applicable).
End date of base year Medicaid (MCD) payment and charge data (if applicable).
Total Medicaid (MCD) Charges for the time period specified in variables 300.1 and 300.2, include if
using a Cost, CCR, or PTC method for determining UPL amount. Leave this blank if using Fee
Schedule.
If variable 224 has a value of "Cost to Charge Ratio" or "Payment to Charge Ratio," then variable 301
should be populated with data.
Total Medicaid non-supplemental payments for base year.
Medicaid supplemental payments associated with the UPL demonstration year. In the notes section,
the state should explain the type(s) of payment reported and the related amount(s). The state may
not report DSH payments as supplemental payments. If not applicable, this variable should be
populated with $0.
Medicaid supplemental payments associated with the UPL demonstration year for GME (Graduate
Medical Education). In the notes section the state should explain the type(s) of payment reported
and the related amount(s). The state may not report DSH payments as supplemental payments. If
not applicable, this variable should be populated with $0.
Other Medicaid supplemental payments (not previously reported in Variables 303.1 or 303.2)
associated with the UPL demonstration year. In the notes section the state should explain the
type(s) of payment reported and the related amount(s). The state may not report DSH payments as
supplemental payments. If not applicable, this variable should be populated with $0.
N/A
Sum of all Medicaid (MCD) Supplemental Payments for the expected payment associated with the
demonstration year, includes the following variables: Variable 303.1 + Variable 303.2 + Variable
303.3.
Description of Medicaid (MCD) payment trend factor used to reflect changes in the Medicaid
program between the base and current UPL Demonstration year periods (e.g., Market Basket).
If the value for variable 308 is anything other than 1.0, then variable 307 should be populated with
data.
Cumulative Medicaid (MCD) payment trend factor used to reflect changes in the Medicaid program
between the base (the midpoint of Variable 300.1 and Variable 300.2) and current UPL
Demonstration year periods (note: 1.00 = no change) (use "mid-point to mid-point approach"). A
value less than 1 or greater than 1.04 for this field will trigger an error.
Cumulative other adjustment (e.g., volume adjustment) factor used to reflect changes in the
Medicaid program between the base (midpoint of variable 300.1 and variable 300.2) and current
UPL Demonstration year periods (note: 1.00 = no change) (use "mid-point to mid-point approach").
Values of blank or zero will trigger an error for this field. Values for this field should not be negative.
N/A

Calculated as Total MCD Supplemental Payments (Variable 306) + (MCD Base Payments (Variable
302) * MCD Inflation Factor (Variable 308) * Other Adjustment to MCD Payments (Variable 309)).
Calculated UPL amount. This will be calculated as described using formulas:
If 203, 204, and 301 all contain numeric values that are not 0, then 400 = 208 * 301.
If 204, 205, and 301 all contain numeric values that are not 0, then 400 = 208 * 301.
If 205 has a numeric value that is not 0 but 204 is blank, 400 = 205.
If 203 and 205 are both blank, then the template will set 400 to zero.
If 203 and 205 are both populated, then the template will set 400 to zero.
N/A
Adjustments made to the UPL that are not otherwise accounted for in the UPL calculation (e.g.,
adjustments for managed care transition, ACA adjustments to the UPL). This field should only
include values that specifically increase or decrease the UPL. These adjustments represent changes
to the UPL prior to the calculation of the UPL gap. If the state provides this as an aggregate
adjustment and does not have this information broken out by individual facilities, these adjustments
should be distributed across all facilities as appropriate. Any adjustments made in this field must be
properly documented and explained in the notes section. If not applicable, this variable should be
populated with $0.
Calculated as Inflated UPL Amount (Variable 406) + Other Adjustments to the UPL Amount (Variable
402). This calculated estimate represents the amount that Medicare would pay for Medicaid
services.
Description of cumulative trend factor used to inflate the Calculated MCD UPL Amount (Variable
400) from the base year to the UPL Demonstration year (e.g., Market Basket).
If the value for variable 405 is anything other than 1.0, then variable 404 should be populated with
data.
Cumulative trend factor used to inflate the MCD UPL Amount (Variable 400) from the base year
(midpoint of Variables 200.1 and 200.2) to the UPL Demonstration year (note: 1.00 = no change)
(use "mid-point to mid-point approach"). A value less than 1 or greater than 1.04 for this field will
trigger an error.
Calculated as MCD UPL Amount (Variable 400) * UPL Inflation Factor (Variable 405).
Calculated as Adjusted MCR UPL Amount (Variable 403) - Inflated MCD Payments to Demonstration
Year (Variable 318).
Adjustments made to the UPL gap. For example, states may utilize this variable to report an
anticipated reduction in payment during the UPL demonstration year. Any adjustments to the UPL
gap should be distributed across all facilities as appropriate and the adjustments must be
documented in the notes section.
Calculated as UPL Gap Amount (Variable 407) + Adjustment to the UPL Gap (Variable 408).
N/A
End of Worksheet

iable, and a key for which of the template tabs the variab

Variable Status
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
N/A
0: Variables Included in Clinic Template
N/A
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

N/A
0: Variables Included in Clinic Template

0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
N/A
0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

N/A
0: Variables Included in Clinic Template

N/A
0: Variables Included in Clinic Template
N/A
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template

0: Variables Included in Clinic Template
0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

N/A
0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

N/A

0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

N/A
0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

0: Variables Included in Clinic Template

0: Variables Included in Clinic Template
0: Variables Included in Clinic Template
0: Variables Included in Clinic Template

0: Variables Included in Clinic Template
N/A

(Required)

(Required)

(Required)

(PIA)

State

Demonstration
Begin Date

Demonstration
End Date

Retrospective/ Prospective
Demonstration

[001]

[002]

[003]

[116]

This cell is intentionally left blank
Demo Info:

Demo Info:

Demo Info:

(Required)

(Required)

(Required)

State

State
Demonstration
Rate Year

Service
Type

[100]

[101]

[102]

Database
Description
&
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(PIA)

This cell is intentio

State Plan Amendment
Number (SPA)

Data Validation Key

[117]

Grey Shading, White
Red Shading only: Required field is left blank. Red Shad
Provider Info:

Provider Info:

Provider Info:

EXAMPLE
EXAMPLE
Provider Info:

(PIA)

(PIA)

(Required)

(Required)

Other State
Provider ID
Number

National
Provider ID
(NPI)

Medicare
Certification
Number
(Medicare ID)

State-specific
Provider ID
(Medicaid ID)

[105]

[109]

[112]

[107]

ading, White Italic Font: Field does not apply to Demonstration Type entered for row.
ding only: Required field is left blank. Red Shading, White BOLD font: Invalid value entered in field.
Provider Info:
Provider Info:
Provider Info:
(Required)

(Required)

(Required)

Provider Name

Ownership
Category
Type

Clinic Type

[108]

[110]

[111]

w.
ntered in field.
MCR Info:

Yellow Shading, Black
EXAMPLE
This cell is intentionally left blank
MCR Info:
MCR Info:

(Required)

(Required)

(Required)

Source of UPL
or Cost Report
Data

UPL Source
Data
Begin Date

UPL Source
Data
End Date

[224]

[200.1]

[200.2]

hading, Black BOLD Font: Duplicate provider info values entered for 1) Elements 105, 112, 107, 108, or 2) Element 109
blank
MCR Info:
MCR Info:
(Required if using CCR)

(Required if using CCR or PTC)

Medicare
Costs

Medicare
Charges

[203]

[204]

En

This cell is intentionally left blank

8, or 2) Element 109
MCR Info:

MCD Info:

(Required if using PTC or Fee Schedule)

(Required)

Medicare
Payments

Time Period of
Medicaid Charge
and Payment Data Begin Date

[205]

[300.1]

End of Worksheet

entionally left blank

MCD Info:

MCD Info:

MCD Info:

MCD Info:

(Required)

(Required if using CCR or PTC)

(Required)

(Required)

Time Period of
Medicaid Charge
and Payment Data End Date

Medicaid
Charges

Medicaid
Base
Payments

Medicaid
Supplemental
Payments

[300.2]

[301]

[302]

[303.1]

MCD Info:

MCD Info:

MCD Inflated
Payment Info:

(Required)

(Required)

(PIA)

Medicaid
Supplemental
Payments
(GME/Training)

Medicaid
Supplemental
Payments
(Other)

Medicaid
Inflation
Factor Type

[303.2]

[303.3]

[307]

MCD Inflated
Payment Info:

MCD Inflated
Payment Info:

(Required)

(Required)

Medicaid
Inflation
Factor

Other Adjustment
to Medicaid
Payments

[308]

[309]

UPL Calc Info:

UPL Calc Info:

(PIA)

(Required)

UPL Inflation
Factor Type

UPL Inflation
Factor

[404]

[405]

UPL Adjustment
Info:

UPL Gap Info:

(Required)

(Required)

Other Adjustments
to the
UPL Amount

Adjustment to
the UPL Gap

[402]

[408]

Clinic
(Required)

(Required)

State

(PIA)
(PIA)
DemonstrationDemonstration
Begin Date End Date
Retrospective/State
Prospective
Plan Amendment
Demonstration
Number (SPA)

[001]
001

[002]
002

[003]
003

[116]
116

[117]
117

Demo Info:

Demo Info:

Demo Info:

Provider Info: Provider Info: Provider Info:

(Required)

(Required)

(Required)

(PIA)

(PIA)

(Required)

State

State
Service
DemonstrationType
Rate Year

Other State
Provider ID
Number

National
Provider ID
(NPI)

Medicare
Certification
Number
(Medicare ID)

Database
Description
&
Variable
Number

(Required)

This cell is intentionally left blank

[100]
[101]
[102]
Demonstration Information
Database Vari
100
101
Variable DescrState

[105]
[109]
[112]
Provider Identification
102
105
109
112
National Provider
Medicare
ID
Certification Number
State Demon-st
Service Type Other State P (NPI)
(Medicare ID)

Detailed DescrState Abbre-viaSpecified by StClinic
No Data
No Data
No Data
No Data
No Data
No Data
No Data
No Data
No Data

Other State PrUnique ID numObtain from M

Page 427

Clinic

ntionally left blank

Provider Info: Provider Info: Provider Info: Provider Info: MCR Info:

MCR Info:

MCR Info:

(Required)

(Required)

(Required)

(Required)

(Required)

(Required)

(Required)

State-specific Provider NameOwnership
Provider ID
Category
(Medicaid ID)
Type

Clinic Type

Source of UPL UPL Source
or Cost ReportData
Data
Begin Date

UPL Source
Data
End Date

[107]

[111]

[108]
107

[110]
108

110

[224]
[200.1]
[200.2]
Medicare Cost or Payment Data (Basis for Calculating UPL) for B
111
224
200.1
200.2

State-specific Provider NameOwnership CatClinic Type (A Source of UPL UPL Source DaUPL Source Da

State ProvidedState ProvidedOwnership CatBased on StateBased on StateObtain from StObtain from St

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Clinic

MCR Info:

MCR Info:

MCR Info:

MCR Info:

MCD Info:

MCD Info:

(Required if using
(Required
CCR) if using
(Required
CCR orifPTC)
using
(Calculated
PTC or Fee
if using
(Required)
Schedule)
CCR or PTC)
(Required)
Medicare
Costs

Medicare
Charges

Medicare
Payments

[203]
[204]
[205]
ta (Basis for Calculating UPL) for Base Period
203
204

MCD Info:
(Required if using CCR or PTC)

Medicare Cost-ToTime Period ofTime Period ofMedicaid
Charge Ratio orMedicaid Charge
Medicaid Charge
Charges
Payment-To-Charge
and Payment Data
and Payment
Data Ratio
Begin Date End Date
[208]
205

[300.1]
[300.2]
[301]
Medicaid Charge and Payment Data for Base Period
208
300.1
300.2
301

Medicare CostMedicare CharMedicare PayMedicare Cost-Time Period ofTime Period o Medicaid Char
Calculate as
CCR as (203/204) or
Specify SourceSpecify sourceSpecify SourcePTC as (205/204)
Specify Time PSpecify Time PTotal Medicaid

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Clinic

MCD Info:

MCD Info:

MCD Info:

MCD Info:

MCD Info:

(Required)

(Required)

(Required)

(Required)

(Calculated) (PIA)

Medicaid
Base
Payments

Medicaid
Medicaid
Medicaid
Total
Medicaid
Supplemental Supplemental Supplemental Medicaid
Inflation
Payments
Payments
Payments
Supplemental Factor Type
(GME/Training)(Other)
Payments

[302]
t Data for Base Period

[303.1]

[303.2]

[303.3]

MCD Inflated MCD Inflated
Payment Info: Payment Info:
(Required)
Medicaid
Inflation
Factor

[306]

[307]
[308]
Medicaid Payments Inflated to Demonstration Ye
302
303.1
303.2
303.3
306
307
308
Medicaid Supplemental
Medicaid Supplemental
Payments
Payments
Medicaid BaseMedicaid Supp(GME/Training)(Other)
Total SupplemMCD Inflation MCD Inflation

Calculate as
Total MedicaidTotal MedicaidTotal MedicaidTotal Medicaid303.1 + 303.2 +Note
303.3
- Inflati Inflation Fact

Page 430

Clinic

MCD Inflated MCD Inflated UPL Calc Info: UPL Calc Info: UPL Calc Info: UPL Calc Info: UPL Adjustment
Payment Info: Payment Info:
Info:
(Required)

(Calculated) (Calculated) (PIA)

(Required)

(Calculated) (Required)

Other Adjustment
Inflated Medicaid
Medicaid UPL UPL Inflation UPL Inflation Inflated UPL Other Adjustments
to Medicaid Payments to Amount
Factor Type Factor
Amount
to the
Payments
Demonstration
UPL Amount
Year

[309]
[318]
[400]
[404]
[405]
[406]
[402]
ents Inflated to Demonstration Year
UPL Calculation (Medicare RCC * Medicaid charges) & Inf Adjustments to UPL
309
318
400
404
405
406
402
Other AdjustmInflated Medi Calculated MeUPL Inflation FUPL Inflation FInflated UPL Other Adjustm
Calculate as
Calculate as 205 if using Medicare fee schedules,
Calculate as
203 if using cost reports, or
Adjustments to306 + (302 * 308
NoteCCR
- Inflati
208* *309)
301 if using
or PTCInflation
methodFact 400 * 405

Page 431

Other Adjustme

Clinic

UPL Adjustment
UPL Gap Info: UPL Gap Info: UPL Gap Info:
Info:
(Calculated) (Calculated) (Required)
Adjusted Medicare
UPL Gap
UPL Amount Amount

[403]
Adjustments to UPL

(Calculated)

Adjustment toAdjusted
the UPL Gap UPL Gap

[407]
[408]
[409]
Calculation of UPL Gap
403
407
408

409

Adjusted MediUPL Gap AmouAdjustment toAdjusted UPL Gap

Calculate as

Calculate as

406 + 402

403 - 318

Calculate as
Any Adjustment
407 + 408

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Clinic

Clinic Obs ID ServiceType + Row Reference

Clinic Obs ID ServiceType + Row Reference

Page 433

Total Dollars by Ownership Type For: Total Base Payments [302], Total Supplemental Payments [306], and Total A
Ownership Category
Total Base Payments
Private
$0
NSGO
$0
SGO
$0
Total
$0

ents [302], Total Supplemental Payments [306], and Total Adjusted UPL Gap [409]
Total Supplemental Payments
Total Adjusted UPL Gaps
$0
$0
$0
$0
$0
$0
$0
$0

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.

This sheet is optional. Please use optional sheets to add any supporting data relevant to the calculation of the UPL demons

ulation of the UPL demonstration content.