CMS-10398 #24 MACFIN_physician-upl-template

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

IX MACFIN_physician-upl-template.xlsx

#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs

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⚠️ Notice: This form may be outdated.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

State Attestation
Overview & Instructions
Data Dictionary
Required State Input – PHYS
Physician
Optional_Sheet_1
Optional_Sheet_2
Optional_Sheet_3
Optional_Sheet_4
Optional_Sheet_5
Optional_Sheet_6
Optional_Sheet_7
Optional_Sheet_8
Optional_Sheet_9
Optional_Sheet_10
Optional_Sheet_11
Optional_Sheet_12
Optional_Sheet_13
Optional_Sheet_14
Optional_Sheet_15

Sheet 1: State Attestation

Upper Payment Limit Demonstration Report		This cell is intentionally left blank
1. I HEREBY CERTIFY that I have read this certification statement and that I have examined the accompanying electronically filed and/or manually submitted Upper Payment Limit demonstration
report prepared by:
(please insert the state Medicaid official (or other person who prepared this UPL demonstration report) Name(s), title(s), and Contact Number(s))
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, have been prepared from the books and records of the providers and Medicaid agency in accordance with applicable instructions. I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that the services identified in this Upper Payment Limit demonstration report are provided in compliance with such laws and regulations.
2. I certify that the costs reported in this Upper Payment Limit demonstration represent a reasonable estimate of the amount that Medicare would pay for these Medicaid services, 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 statement, and the source(s) of such state and/or local funds are in accordance with all applicable federal requirements for the non-federal share of expenditures (including that the funds are not Federal funds in origin or are Federal funds authorized by Federal law to be used to match other Federal funds, and that the federal funds received to match the claimed expenditures will not be used to meet matching requirements under other Federally funded programs).
4. I understand that this information may be used as a basis for claims for federal funds, and that falsification and concealment of a material fact may be prosecuted under federal or state 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 determination of the UPL amount, including supplemental materials used to complete the template. I certify that, to the best of my knowledge and belief, none of the calculations or formulas in the template have been changed, and the most recent version 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 altered in any way, all applicable instructions in the guidelines and directions have been followed in completing this UPL demonstration, and the template has been completed consistent with the definitions in the data dictionary.
7. I am the officer authorized by the relevant state government agency to submit this form and I have made a good faith effort to ensure that all information reported is true and accurate.
Electronic Signature:
Title & Contact Information:
End of Worksheet

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:

CMS Accountability Guidance

CMS is also introducing templates specific to each service 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 facility, please complete the "Required State Input – PHYS" tab. Please ensure the top section of the input tab in the template is completed, which includes the state, the start date for the demonstration, and the end date for the demonstration. This is used to ensure 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 valid data for the specified cell, the template will remove the red color from the cell. For details about the valid data format and valid values for each variable, please see the Data Dictionary tab.

States may not enter data into the tab labeled "Physician." The template calculates the content on these tabs 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 supplementary data needed to calculate the content for the "Required State Input – PHYS" tab. These sheets are optional. If you choose to enter data in the optional worksheet tabs, 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 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 the input tabs within these templates, data for each individual provider should be included on one 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 unless otherwise noted in the data dictionary.

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

CMS has developed an instructional document for qualified practitioner services to help states create their UPL demonstration. This document can be downloaded from:

CMS UPL Instructions for Qualified Practitioner 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 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 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 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 hours 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 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 Designation	Variable Format	Short Description	Long Description	Variable Status
001	Required	2-character text	State	2-character state ID (e.g., Connecticut = CT)	0: Variables Included in Physician Template
002	Required	Date [MM/DD/YYYY]	Demonstration Begin Date	Start date of the State demonstration rate year	0: Variables Included in Physician Template
003	Required	Date [MM/DD/YYYY]	Demonstration End Date	End date of the State demonstration rate year	0: Variables Included in Physician Template
100	Required	2-character text	State	2-character state ID (e.g., Connecticut = CT)	0: Variables Included in Physician Template
101	Required	4-digit number	State Demonstration Rate Year	State demonstration rate year YYYY (e.g., 2014)	0: Variables Included in Physician Template
102	Required	2-character text	Service Type	Service type: Physician	0: Variables Included in Physician Template
103	Not Applicable to this Template (N/A)	N/A	N/A	N/A	N/A
104	Required	Text	Demonstration Type (ACR, MCR Equivalent)	Demonstration type. Enter either "ACR" or "MCR Equivalent" (ACR = Average Commercial Rate; MCR Equivalent = MCR Equivalent Payment)	0: Variables Included in Physician Template
105	Provide if Applicable (PIA)	Unspecified	Other State Provider ID Number	State provider ID number that is not a Medicaid (MCD) ID number (if applicable).	0: Variables Included in Physician Template
106	N/A	N/A	N/A	N/A	N/A
107	Required	Unspecified	State-specific Provider ID (MCD ID)	Medicaid (MCD) ID number.	0: Variables Included in Physician Template
108	Required	Text	Provider Name	Provider name	0: Variables Included in Physician Template
109	Provide if Applicable (PIA)	10-11 digit number	National Provider ID (NPI)	National Provider Identification Number	0: Variables Included in Physician Template
110-111	N/A	N/A	N/A	N/A	N/A
112	Required	6-digit number	MCR Certification Number (MCR ID)	Medicare (MCR) ID number. In the instances where a facility is Not Medicare Certified (NMC), the state should enter "NMC."	0: Variables Included in Physician Template
113-115	N/A	N/A	N/A	N/A	N/A
116	Provide if Applicable (PIA)	Text	Retrospective/Prospective Demonstration	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.	0: Variables Included in Physician Template
117	Provide if Applicable (PIA)	2-character text with 2-digit numbers and 4-digit number separated by hyphen	State Plan Amendment (SPA) Number	The state plan amendment number associated with the demonstration submission. The expected format is: 2 letter state abbreviation-##-#### (for example, OR-19-0002).	0: Variables Included in Physician Template
200.1	Required if Medicare Equivalent of ACR Approach	Date [MM/DD/YYYY]	MCR Rate Period - Begin Date	Medicare (MCR) Physician Fee Schedule begin date. Leave blank if using an average commercial rate (ACR) Approach. If variable 104 has a value of "Medicare Equivalent," then variable 200.1 should be populated with data.	0: Variables Included in Physician Template
200.2	Required if Medicare Equivalent of ACR Approach	Date [MM/DD/YYYY]	MCR Rate Period - End Date	Medicare (MCR) Physician Fee Schedule end date. Leave blank if using an average commercial rate (ACR) Approach. If variable 104 has a value of "Medicare Equivalent," then variable 200.2 should be populated with data.	0: Variables Included in Physician Template
201-224	N/A	N/A	N/A	N/A	N/A
225	Required if Medicare Equivalent of ACR Approach	$ Amount	MCR Payment Amount	Calculated as the practitioner's average Medicare (MCR) payment rate multiplied by its Medicaid (MCD) volume. Leave blank if using an average commercial rate (ACR) Approach. If variable 104 has a value of "Medicare Equivalent," then variable 225 should be populated with data.	0: Variables Included in Physician Template
226	Required if Medicare Equivalent of ACR Approach	Proportion	ACR as Percent of MCR Rate	Provider's average commercial rate (ACR) divided by its average Medicare (MCR) rate. Leave blank if using an ACR Approach. If variable 104 has a value of "Medicare Equivalent," then variable 226 should be populated with data.	0: Variables Included in Physician Template
300.1	Required	Date [MM/DD/YYYY]	Time Period of MCD Payment Data - Begin Date	Beginning date of base year Medicaid (MCD) payment data.	0: Variables Included in Physician Template
300.2	Required	Date [MM/DD/YYYY]	Time Period of MCD Payment Data - End Date	End date of base year Medicaid (MCD) payment data.	0: Variables Included in Physician Template
301	N/A	N/A	N/A	N/A	N/A
302	Required	$ Amount	MCD Base Payments	Total Medicaid non-supplemental payments for base year.	0: Variables Included in Physician Template
303	N/A	N/A	N/A	N/A	N/A
304	Required	Number	MCD Volume of Services	Volume of services used for computing service weighted Medicaid payments and enhanced payment amount.	0: Variables Included in Physician Template
305-318	N/A	N/A	N/A	N/A	N/A
400-419	N/A	N/A	N/A	N/A	N/A
420.1	Required if ACR Approach	Date [MM/DD/YYYY]	Time Period of Commercial Rate Data - Begin Date	Beginning date of commercial rate data. Leave blank if using a Medicare Equivalent of ACR Approach. If variable 104 has a value of "ACR," then variable 420.1 should be populated with data.	0: Variables Included in Physician Template
420.2	Required if ACR Approach	Date [MM/DD/YYYY]	Time Period of Commercial Rate Data - End Date	End date of commercial rate data. Leave blank if using a Medicare Equivalent of ACR Approach. If variable 104 has a value of "ACR," then variable 420.2 should be populated with data.	0: Variables Included in Physician Template
421	N/A	N/A	N/A	N/A	N/A
422	Required if ACR Approach	$ Amount	Average Commercial Rate (ACR)	Calculated as the provider's average commercial rate (ACR) multiplied by its Medicaid volume. Leave blank if using a Medicare Equivalent of ACR Approach. If variable 104 has a value of "ACR," then variable 422 should be populated with data.	0: Variables Included in Physician Template
423	State Calculated	$ 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) * ACR as Percent of MCR Rate (Variable 226) The state must calculate this as described using formulas.	0: Variables Included in Physician Template
424	Calculated	$ Amount	Maximum Supplemental Payments	Calculate as Enhanced Payment Amount (Variable 423) - MCD Base Payments (Variable 302).	0: Variables Included in Physician Template
End of Worksheet

Sheet 4: Required State Input – PHYS

(Required)

State

[001]

(Required)

Demonstration
Begin Date

[002]

(Required)

Demonstration
End Date

[003]

(PIA)

Retrospective/ Prospective Demonstration

[116]

(PIA)

State Plan Amendment Number (SPA)

[117]

This cell is intentionally left blank

Data Validation Key

This cell is intentionally left blank

EXAMPLE

Grey Shading, White Italic Font: Field does not apply to Demonstration Type entered for row.

EXAMPLE

Yellow Shading, Black BOLD Font: Duplicate provider info values entered for 1) Elements 105, 112, 107, 108, or 2) Element 109

This cell is intentionally left blank

EXAMPLE

Red Shading only: Required field is left blank. Red Shading, White BOLD font: Invalid value entered in field.

This cell is intentionally left blank

Database
Description &

Variable
Number

Demo Info:

(Required)

State

[100]

Demo Info:

(Required)

State
Demonstration
Rate Year

[101]

Demo Info:

(Required)

Service
Type

[102]

Demo Info:

(Required)

Demonstration
Type

[104]

Provider Info:

(PIA)

Other State
Provider ID
Number

[105]

Provider Info:

(PIA)

National
Provider ID
(NPI)

[109]

Provider Info:

(Required)

Medicare
Certification
Number
(Medicare ID)

[112]

Provider Info:

(Required)

State-specific
Provider ID
(Medicaid ID)

[107]

Provider Info:

(Required)

Provider Name

[108]

MCR Payment Info:

(Required if Medicare Equivalent of ACR approach)

Time Period of
Medicare Rates -
Begin Date

[200.1]

MCR Payment Info:

(Required if Medicare Equivalent of ACR approach)

Time Period of
Medicare Rates -
End Date

[200.2]

MCR Payment Info:

(Required if Medicare Equivalent of ACR approach)

Medicare
Payment
Amount

[225]

MCR Payment Info:

(Required if Medicare Equivalent of ACR approach)

ACR as
Percent of
Medicare
Rate

[226]

MCD Payment and
Volume Info:

(Required)

Time Period of
Medicaid
Payment Data -
Begin Date

[300.1]

MCD Payment and
Volume Info:

(Required)

Time Period of
Medicaid
Payment Data -
End Date

[300.2]

MCD Payment and
Volume Info:

(Required)

Medicaid
Base
Payments

[302]

MCD Payment and
Volume Info:

(Required)

Medicaid
Volume
of Services

[304]

Avg Commercial
Rate Info:

(Required if ACR approach)

Time Period of
Commercial Rate Data -
Begin Date

[420.1]

Avg Commercial
Rate Info:

(Required if ACR approach)

Time Period of
Commercial Rate Data -
End Date

[420.2]

Avg Commercial
Rate Info:

(Required if ACR approach)

Average
Commercial Rate
(ACR)

[422]

ACR Max. Supplemental
Payment Info:

(State Calculated)

Enhanced
Payment
Amount

[423]

No Data

End of Worksheet

Sheet 5: Physician