CMS-10398 #24 Guidance Questions_Master File_Physician

No.
Section I: UPL Demonstration Overview:
1

2

UPL Guidance Question

Response or Follow-Up Questions

Are there any significant changes to the prior UPL methodology?

Insert the following options:
Yes
No

Does the UPL demonstration align with your state fiscal year?

If 'Yes' is selected, insert the following question:
If Yes, please explain.
Insert Text Box
Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain.
Insert Text box

3

4

5

Does the UPL demonstration include a full 12 months of data for each provider?

Is the beginning date of the data more than 2 years from the beginning date of the UPL
demonstration period?

Has the provider count changed from the previous UPL demonstration?

Add the following note:
Note: The UPL demonstration period should start the day after the previous UPL demonstration period’s end date.
Insert the following options:
Yes
No
If 'No' is selected, insert the following question:
If No, please explain.
Insert Text Box
Insert the following options:
Yes
No
If 'Yes' is selected, insert the following question:
If Yes, please explain.
Insert Text box
Insert the following options:
Yes
No
If 'Yes' is selected, proceed to question 5a.

5a
Section II: Type of Demonstration and Payment Methodology
1

Please explain the changes, including any new providers, closed providers, or mergers.
Please also cite the source of this data.
Which type of demonstration is used to demonstrate the enhanced payments?

Insert Text Box
Average Commercial Rate
Medicare Equivalent of the Average Commercial Rate
If more than one demonstration type is selected, explain which providers receive each kind of payment. (Note: If only one
demonstration type is selected then enter "not applicable").
Insert Text Box
If user selects ACR then display question 2
If user selects Medicare Equivalent of the ACR then display question 3

2

Indicate the payment methodology for the enhanced payments (Average Commercial
Rate)

Alternative Fee Schedule
Supplemental payments to the base rates
If the user selects Alternate Fee Schedule then display the following question:
2a. Indicate the percentage of the Average Commercial Rate (ACR) that is paid (up to 100%) using the Alternative Fee Schedule
Insert Text box
If the user selects Supplemental payments to the baser rates then display the following questions:
2b. Indicate the percentage of the Average Commercial Rate (ACR) that is paid (up to 100%) using Supplemental Payments to
the base rates
Insert Text Box

3

2c. Describe the base payment methodology for which the supplemental payments are attributed
Insert Text box
Indicate the payment methodology for the enhanced payments (Medicare Equivalent of Alternative Fee Schedule
Supplemental payments to the base rates
the Average Commercial Rate)
If the user selects Alternate Fee Schedule then display the following question:
3a. Indicate the Medicare Equivalent of the Average Commercial Rate percentage that is paid using the Alternative Fee
Schedule.
Insert Text box
If the user selects Supplemental payments to the baser rates then display the following questions:
3b. Indicate the Medicare Equivalent of the Average Commercial Rate percentage that is paid using Supplemental Payments to
the base rates.
Insert Text Box
3c. Describe the base payment methodology for which the supplemental payments are attributed.
Insert Text box

Section III. Data Requirements
Information about Payers (Sub-section)
1

Payment Data (Sub-section)

Select from the following options:

2

Are the third-party payer data derived from the billing systems of the providers eligible
for the enhanced payment?

1

Do the payments include all copayments and deductibles?
The amount of allowed payment by the third party payers includes payment and any
patient liability that together equal the total payment for a service allowed by a
commercial payer.

2

Insert the following options:
The ACR or Medicare Equivalent of the ACR demonstration includes the top (generally five) commercial payers.
The ACR or Medicare Equivalent of the ACR demonstration includes all commercial payers.
Insert the following options:
Yes
No

Insert the following options:
Yes
No

Note: States must be able to clearly demonstrate how the allowed payment amount was If No is selected, insert the following question:
If No, please explain.
determined under each of the accounts receivable systems of the eligible providers.
Insert Text Box
Insert the following options:
When an enhanced payment is made, is the payment data included for each CPT code
Yes
provided by the groups of eligible practitioners?
No
If No is selected, insert the following question:
If No, please explain.
Insert Text Box

Authorized Codes, Dates of Service, and MMIS Data (Sub-Section)
1

Please confirm that the supplemental payment is made only for codes for which base
payments are made and that the ACR demonstration includes only those same codes.
Codes that do not receive base payments cannot be included in the ACR demonstration
and therefore cannot receive supplemental or enhanced payment.

2

What are the dates of service of the commercial data used in the demonstration?

3

What are the dates of the Medicaid payment and volume data used in the
demonstration?

Insert confirmation/verification check box
Dates of Service:
Insert Text Box
Dates of Service:
Insert Text Box

4

5

6

Do the dates of service in the commercial payment data match the dates of service for
the Medicaid payment/volume data from MMIS?
For supplemental/enhanced payments made for time periods that are after the date of
the ACR calculation, states must use commercial payment data that is no more than two Insert the following options:
Yes
years old to calculate the ACR.
No
Note: For supplemental/enhanced payments that are made for concurrent ACR
If No is selected, insert the following question:
demonstration time periods, dates of service in the commercial payment data must
If No, please explain.
match the dates of service included in the Medicaid payment/volume from MMIS.
Insert Text Box
Is primary commercial payment source information, such as a payment invoice, provided Insert the following options:
Yes
for at least one billing code, showing how the ACR was calculated?
No

Are the Medicaid payment and volume data derived from the MMIS?
Note: Using MMIS helps to assure that Medicaid payment has been adjusted for dual
eligible liabilities and that payment is associated with covered services delivered to
Medicaid beneficiaries.

Payers not Subject to Market Forces and Managed Care (Sub-section)
1

2

3

If Yes is selected, insert the following question:
If Yes, please list the billing code or codes provided.
Insert Text Box
Insert the following options:
Yes
No
If No is selected, insert the following question:
If No, please describe the different source from which Medicaid payment and volume data are derived.
Insert Text Box

Are FQHCs, RHCs, Medicare, Workers Compensation, and other payers’ data that are not Insert the following options:
Yes
subject to market forces excluded from the demonstration?
No
Insert the following options:
Are managed care payments made on a capitation or sub-capitation basis excluded?
Yes
No
Insert the following options:
Are managed care entity fee for service payments included?
Yes
No
If Yes is selected, insert the following question:
If Yes, please explain which services are paid on a fee for service basis, which managed care entities’ data are included, and
identify the state plan authority and location for these payments.
Insert Text Box

Dually Eligible Beneficiaries (Sub-section)
1

Do the enhanced payments and data exclude services provided to beneficiaries who are
dually eligible for Medicaid and Medicare?

Insert the following options:
Yes
No
If No is selected, insert the following question:
If No, please document the authority provided in Supplement 1 to Attachment 4.19-B in the following text box
Note: Supplement 1 to Attachment 4.19-B of the state plan describes the payment methodology for Medicare Part A and Part B
deductibles and co-insurance, as well as any instances of payment for services that are not covered by Medicare. If authorized
by the state plan, in these limited circumstances Medicaid may become the primary payer of services and in these cases these
data may be included in the calculation of the enhanced payments. If the state plan does not authorize payment for services not
covered by Medicare, these data must be excluded from the calculation of enhanced payment.
Insert Text Box

2
Eligible Providers and Practitioners (Sub-section)
1

2

3

Describe how payments and charges for which Medicaid is the primary payer are
identified.

Insert Text Box

List all providers eligible for enhanced payment by campus, geographic location, or some
other criteria. This list will identify all academic medical centers, hospitals, and/or other
Insert Text Box
providers that will participate in the enhanced payment.
Does the demonstration include separate provider-specific ACR calculations or does it
calculate only one ACR that includes all providers of these provider-specific payments?
Note: If the state is paying providers up to a provider-specific average commercial rate,
the demonstration must include separate calculations for each of the providers eligible to Insert the following options:
Separate Provider-Specific ACR Calculations
receive the enhanced/supplemental payment.
One ACR Calculation that Includes All Providers
Insert the following options:
Are enhanced payments made to non-physicians practitioners?
Yes
No
If Yes is selected, insert the following question:
If Yes, please list all eligible provider types.
Insert Text Box

4

5

Are data included in the demonstration for all of the types of practitioners whose services
are eligible for the enhanced/supplemental payment?
Note: In order for a provider to receive enhanced/supplemental payments, the state
must provide commercial and Medicaid data for that provider.
Are supplemental payments made for providers working under the supervision of a
physician?

Insert the following options:
Yes
No

6

Note: Under 42 CFR 440.50(a) physician services are defined as services furnished by a
physician (1) within the scope of practice or medicine or osteopathy as defined by State
law; and by or under the personal supervision of an individual licensed under State law to
practice medicine or osteopathy. Therefore, the services by providers working under the
supervision of a physician, such as nurse practitioners and physicians’ assistants may be Insert the following options:
Yes
paid at the enhanced rate or supplemental ACR payment.
No
Are supplemental payments made for non-physician practitioners?

7

Note: The services of non-physician practitioners, which may include practitioners who
are enrolled, qualified Medicaid providers can be targeted for increased payment, subject
to an ACR demonstration.
Are non-professional services excluded from the data?

8

Please describe how the services of all providers that are eligible for the
enhanced/supplemental payment were identified.
Radiology, Clinical Diagnostic Laboratories, and Anesthesia Services (Sub-section)
1
Does the demonstration exclude the technical component of radiology services?

2

Insert the following options:
Yes
No
Insert the following options:
Yes
No
Insert Text Box

Note: Radiology services as found in the 70000 CPT series can include both a professional
and non-professional, or a technical component that may be paid either separately or
through a bundled rate. The technical component is meant to pay for materials used to
perform a radiology procedure and is denoted in the billing code with a “TC” modifier.
The professional component recognizes physician work associated with reading radiology
Insert the following options:
films. Only the professional component of radiology services should be included in the
Yes
demonstration if an enhanced payment is made for radiology services.
No
Insert the following options:
Are any clinical diagnostic laboratory (CDL) services included in the demonstration?
Yes
No
If the user selects "Yes" for this question then questions 2a and 2b should be made available.
If the user selects "No" then do not ask 2a and 2b.

2a

2b
3

Are payments for these services made at or below the Medicare rate on a per test basis,
as required by section 1903(i)(7) of the Social Security Act?
Note: Clinical diagnostic laboratory services as found in the 80000 CPT coding series are
mostly non-physician services and are subject to an upper payment limit at section
1903(i)(7) of the Act. The upper payment is limited to the amount Medicare would pay on Insert the following options:
Yes
a per test basis or, a per code basis for a bundled/panel of tests.
No
Insert Text Box
Please list any CDL codes that have been included in the demonstration.
Please explain if the Medicaid payment for anesthesia services directly crosswalks to
Medicare payment. In the explanation also indicate if the Medicaid payments are made
using the same units of service for time increments as Medicare. If Medicaid does not
directly crosswalk to Medicare, please explain how the methodology addresses any
differences between the Medicare and Medicaid services.
Note: Medicare (and other third party providers) reimburses providers a base amount for
each service/CPT Code in addition to an incremental amount for the amount of time used
to deliver the service. CMS has found that States do not necessarily measure time in the
same way that Medicare does, which is by 15-minute unit. Additionally, if the State
included services of CRNA’s (certified registered nurse anesthetists) or other nonphysicians rendering anesthesia, those services will be denoted by CPT Codes with
modifier “QX” and are usually reimbursed by both commercial payers and Medicaid at a
percentage of the fee paid to physicians.
Insert Text Box

Section IV: Steps in Calculating Payment Ceiling using the ACR
The average commercial rate (ACR) is used to establish a payment ceiling
for supplemental payments to qualified, enrolled Medicaid practitioners. In
order for CMS to evaluate if these payments comport with section
1902(a)(30(A) of the Act, which specifies that payments must be efficient
and economic, states should submit, in spreadsheet form, a detailed
calculation of the average commercial rate (ACR) or the Medicare
equivalent of the ACR for all procedure codes eligible for payment to
demonstrate how the upper limit of payment was established for
practitioner supplemental payments. In addition, states should submit a
copy of the invoice which accompanies payment from one of the top
commercial payers to document how it identified the allowed amount for
at least one code included in the demonstration. The names of the
commercial payer(s) on the invoice as well as the spreadsheet detailing the
commercial payments can be masked to hide the identity of the payers.
States must, however, disclose the names of the commercial payers
included in the calculation of the ACR.
The steps below describe the methodology that states can use to calculate
the ACR to establish an upper payment ceiling for practitioner
supplemental payments.
Step 1: Compute the Average Commercial Rate
Calculate the average commercial rate per procedure code from the
allowed payment amount from each eligible provider’s billing system for
the top (generally five), or for all, commercial third party payers (TPP) for
the base period. Please see the narrative for further explanation and
instructions in calculating the ACR per procedure.
1
Step 2: Calculate the Payment Ceiling

Please indicate the name of the spreadsheet submitted to document the detailed
calculation of the ACR.

Insert Text Box

a. Multiply the average commercial rate as determined in Step 1 by the
number of claims recorded in MMIS for each procedure code that was
rendered to Medicaid beneficiaries by eligible practitioners during the base
period used for Step 1.
b. Add the product for all procedure codes. This total represents the
supplemental/enhanced payment ceiling. Note, if enhanced payment is
made on a per code basis, the payment ceiling will be a per code ceiling that
equals the product of the ACR and the Medicaid volume for that code.
1

Has a payment ceiling been calculated for all practitioners eligible for
enhanced/supplemental payment?

2

How is the supplemental/enhanced payment made?

3

4

Section V: Medicare Equivalent of the Average Commercial Rate
Demonstrations

Note: Any supplemental or enhanced payment can only be made up to a maximum of
the payment ceiling less Medicaid payment in total from MMIS.
Were practitioner supplemental/enhanced payments the net of MMIS payments for the
eligible codes paid to eligible practitioners?

Insert the following options:
Yes
No
Insert the following options:
The supplemental/enhanced payment is made on a per code payment ceiling basis
The supplemental/enhanced payment is made on the aggregate payment ceiling (the sum of all per code payment ceilings)
Insert the following options:
Yes
No

Please indicate the date of the last ACR payment ceiling calculation.
Note: If the ACR is used to determine practitioner supplemental payment, the ACR
payment ceiling must be calculated annually.

Insert Text Box

Please indicate the name of the spreadsheet(s) submitted to document the detailed
calculation of the ACR for the procedure codes, by eligible provider, for which
supplemental payment will be made.

Insert Text Box

States may make supplemental/enhanced payments using the Medicare
equivalent of the average commercial rate (ACR). This methodology
establishes a ratio of commercial payment to Medicare payment to
calculate the supplemental/enhanced payment. This ratio is a single
statistic that is multiplied by the Medicare payment for all procedure codes
eligible for supplemental payment. The supplemental payment ceiling
equals the enhanced payment amount multiplied by the Medicaid volume
incurred for each eligible procedure code.
The steps below describe the methodology that states can use to calculate
the Medicare equivalent of the ACR to establish an upper payment ceiling
for practitioner supplemental payments.
Step 1: Calculate the Average Commercial Rate
Calculate the average commercial rate per procedure code from the
allowed payment amount from each eligible provider’s billing system for
the top (generally five), or for all, commercial third party payers (TPPs) for
the base period. Please see Step 1 of the narrative section for ACR
demonstrations for further explanation and instructions in calculating the
ACR per procedure.
1

Step 2: Calculate the Medicaid Payment Ceiling
An aggregate Medicaid payment ceiling must be calculated. For each of the
billing codes for which practitioner supplemental payments are to be made,
the ACR for each code is multiplied by Medicaid volume to calculate the
amount that would have been paid using the average commercial rate. The
resulting amount is the payment ceiling per code; the total payment ceiling
is calculated by summing the product of all codes per provider for the codes
for which supplemental payment is to be made.
Multiply the average commercial rate as determined in Step 1 by the
number of claims recorded in MMIS for the same time period as the ACR,
per eligible practitioner for each procedure code that was rendered to
Medicaid beneficiaries. Sum the product of all procedure codes by provider
to calculate the aggregate Medicaid payment ceiling.
1

Has the Medicaid payment ceiling been calculated for each procedure code for which
enhanced payment is to be made for eligible Medicaid practitioners?

2

Has the total aggregate Medicaid payment ceiling been calculated for each eligible
Medicaid practitioner?

Insert the following options:
Yes
No
Insert the following options:
Yes
No

Step 3: Calculate the Average Commercial Rate as a Percentage of Medicare
Multiply the Medicare rate per procedure code by the number of claims
recorded in MMIS for each procedure code that was rendered to Medicaid
beneficiaries during the base period used for Step 1. Add the product for all
procedure codes; this sum represents total Medicare payment that would
have been received. Divide the total Medicaid payment ceiling by total
Medicare payments. This single statistic expresses the ACR as a percentage
of Medicare and will be used to calculate enhanced Medicare payment
rates for determining supplemental payments (Step 4).
The Medicare fee schedule used for the calculation of the Medicare
equivalent of the ACR single statistic must be specified in the state plan. In
addition, only Medicare fees for procedures that are authorized by the
Medicaid state plan can be included in the calculations.
Insert the following options:
Yes
No

1

Are all Medicaid services matched to Medicare services by CPT/billing code?

2

Please confirm that the Medicare Physician Fee Schedule is from the same time period as
the rates obtained from the commercial payers, the Medicaid rates and the Medicaid
Insert confirmation/verification check box
services provided.
Date:
Please indicate the RVUs issued by Medicare as of:
Insert Text Box
Insert the following options:
Do RVUs vary by site of service?
Yes
No
Insert the following options:
Are facility RVUs used?
Yes
No
Insert the following options:
Are non-facility RVUs used?
Yes
No
Insert the following options:
Do the RVUs vary by geographic locale as defined by Medicare?
Yes
No
Insert the following options:
Does the state update its methodology within a single rate year?
Yes
No

3
4

5

6

7

8

Step 4: Calculate Total Maximum Supplemental Payment
The total maximum supplemental payment per provider is calculated by
multiplying the Medicare equivalent of the ACR (the single statistic) by the
Medicare rate for each eligible procedure code, summing the product of
each code, and subtracting MMIS payments per eligible procedure code for
which supplemental payment is to be made. The total supplemental
payment for each eligible provider can be made only up to this net amount.
Enhanced payment can be made on a per code basis, which would be equal
to the single statistic multiplied by the Medicare rate per code. If this
payment methodology is used, all base Medicaid payments must be
subtracted for each procedure code to determine the maximum
supplemental payment amount that can be made for that code.
1

2

3

4

5

6

7

Insert the following options:
Yes
No
Insert the following options:
Is the volume of eligible procedure codes reported from MMIS claims per eligible
Yes
practitioner?
No
Is the maximum supplemental payment per eligible practitioner equal to, or less than, the Insert the following options:
Yes
Medicaid payment ceiling per practitioner, respectively?
No
Have paid claims from MMIS for the same time period as the volume reported for each Insert the following options:
Yes
eligible practitioner been subtracted from the sum of the enhanced payment rate
No
multiplied by volume per provider?
How are supplemental/enhanced payments made?
Insert the following options:
Payments are made per code, rather than as an aggregate amount equal to the sum of the enhanced payment per code
Payments are made based on the aggregate amount, or sum, of all eligible procedure codes
Insert the following options:
Is the total net supplemental payment (enhanced payment less Medicaid payment)
Yes
reported per eligible practitioner?
No

Are supplemental payments at or below the maximum net supplemental payments as
calculated per eligible practitioner?
Is the Medicare equivalent of the ACR multiplied by the Medicare rate for all eligible
codes for procedures reported in MMIS?

Note: Any supplemental or enhanced payment can only be made up to a maximum of
the payment ceiling less Medicaid payment in total from MMIS (net supplemental
payments) for each eligible provider.

Insert the following options:
Yes
No