(Medicare Claims Processing Manual)

The PROV file contains needed information about each provider to enable the pricing software to calculate the payment amount.  The FI maintains the accuracy of the data in accordance with the following criteria.   Whenever the status of any element changes, the FI prepares an additional record showing the effective date.  For example, when a hospital's FY beginning date changes as a result of a change in ownership or other "good cause," the FI makes an additional record showing the effective date of the change.   The format and data required by the PRICER program and by the provider-specific file is found in Addendum A.  The FIs submit a file of provider-specific payment data to CMS CO every three months for PPS and non- PPS hospitals, inpatient rehabilitation hospitals or units (referred to as IRFs), long term care hospitals (LTCHs), inpatient psychiatric facilities (IPFs), SNFs, and hospices, including those in Maryland.  Regional home health FIs (RHHIs) submit a file of provider specific data for all home health agencies.  FIs serving as the audit FI for hospital based HHAs do not submit a file of provider specific data f or HHAs.   The FIs create a new record any time a change occurs for a provider.  Data must be reported for the following periods:  October 2 - January 1, January 2 - April 1, April 2 - July 1, and July 2 - October 1.  This file must be received in CO within seven business days after the end of the period being reported.  NOTE:   FIs submit the latest available provider -specific data for the entire reporting period to CO by the seven -business day deadline.  If CO fails to issue applicable instructions concerning changes or additions to the file fields by 10 calendar days before the end of the reporting period, the FI may delay reporting of data related to the CO instructions until the next file due date.  For example, if CO instructions changing a file field are issued on or after September 21 with an effective date of October 1, the FI may exclude the October 1 CO-required changes from the file submitted by October 9.  The FI includes the October 1 CO-required changes, and all subsequent changes through January 1 in the file submitted in January.  A.  PPS Hospitals  The FIs submit all records (past and current) for all PPS providers every three months.  Duplicate the provider file used in the "PRICER" module of the claims processing system.   B.  Non- PPS Hospitals and Exempt Units   The FIs create a provider specific history file using the listed data elements for each non -PPS hospital and exempt hospital unit.  Submit the current and the preceding fiscal years every three months.  Code Y in position 49 (waiver code) to maintain the r ecord in the PRICER PROV file.   C.  Hospice  The FIs create a provider specific history file using the following data elements for each hospice.  Submit the current and the preceding fiscal years every three months.  Data elements 3, 4, 5, 6, 9, 10, 13, and 17 are required.  All other data elements are optional for this provider type.  Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still required.  Data element 35 is required for all hospices.  Data elements 33 and 38 are optional and may be populated if needed.   Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.   D.  Skilled Nursing Facility (SNF)   The FIs create a provider specific history file using the following data elements for each SNF beginning with their first cost reporting period that starts on or after July 1, 1998. The FIs submit the current and the preceding fiscal years every three months.  For PPS -exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file.  Data elements 3, 4, 5, 6, 9, 10, 13, 19, and 21 are required.  All  other data elements are optional for this provider type.   Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still required.  Data element 35 is required for all SNFs.  Data elements 33 and 38 are required if there is a special wage index.  Effective October 1, 2005, through September 30, 2006, data elements 33 and 38 are required since there is a special wage index.   E.  Home Health Agency (HHA)   The FIs create a provider specific history file using the following data elements for each HHA.  Regional home health FIs (RHHIs) submit the current and the preceding fiscal years every three months.  Data elements 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 19 and 30 are required.  All other data elements are optional for this provider type.  All fields must be zero filled if not completed.  Update the effective date in data element 4 annually.  Ensure that the current census division in data element 11 is not zero.  Ensure that the waiver indicator in data element 8 is N.  Ensure that the MSA code reported in data element 13 is a valid MSA code.   F.  Inpatient Rehabilitation Facilities (IRFs)   The FIs create a provider specific history file using the following data elements for each IRF beginning with their first cost reporting period that starts on or after January 1, 2002.  FIs submit the current and the preceding fiscal years every three mont hs.  For PPS -exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file.  Data elements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 18, 19, 21, 25, 27, 28, and 42 are required.  All other data elements are optional for this provider type.  Effective October 1, 2005, data element 13 is no longer applicable to payment applications but is still required.  Data element 35 is required for all IRFs.  Data elements 17, 33, 38, and 49 are required if applicable to the IRF.   Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.   G.  Long Term Care Hospital (LTCH)   The FIs create a provider specific history file using the following data elements for each LTCH beginning with their first cost reporting period that starts on or after October 1, 2002.  FIs submit the current and the preceding fiscal years every three mon ths.  For PPS -exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file.  Data elements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 12, 13, 14, 18, 19, 21, 22, and 25 are the minimum required fields for entering a provider und er LTCH PPS.   Effective July 1, 2005, data element 35 is required.  Data elements 33 and 38 are optional and may be populated if needed.  Data elements 12, 13, and 14 are no longer applicable.  Effective July 1, 2006, data elements 23, 24, 27, 28, and 49 are required.  Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.   H.  Inpatient Psychiatric Facilities (IPF)   The FIs create a provider specific history file using the following data elements for each IPF beginning with their first cost reporting period that starts on or after January 1, 2005.  The FIs submit the current and the preceding fiscal years every three months.  For PPS-exempt providers, code Y in position 49 (waiver code) to maintain the record in the PRICER PROV file.  Data elements 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 13, 17, 18, 19, 21, 22, 23, 25, 33, 35, 38, and 48 are required.  All other data elements are optional for this provider type.  Although data element 25 refers to the operating cost to charge ratio, ensure that both operating and capital cost- to-charge ratio are entered in dat a element 25 for IPFs.  Ensure that data element 21 (Facility Specific Rate) will be determined using the same methodology to determine the interim payment per discharge under the TEFRA system.  Effective July 1, 2006, data element 13 is no longer required.  Data elements 33 and 38 are optional and may be populated if needed.  Effective October 1, 2013, data element 34 (Hospital Quality Indicator) is required.  NOTE:  All data elements, whether required or optional, must have a default value of 0 (zero) if numerical, or a blank value if alphanumerical.   The provider specific file (PSF) should be transferred to CO using the Network Data Mover (NDM) system, COPY TO and RUN JOB statements, which will notify CO of PSF file transfer.  FIs must set up an NDM transfer from the FI's system for which it is respons ible.  It is critical that the provider specific data is copied to the CMS Data Center using the following input data set names ("99999" should be changed to the FI's 5-digit number):  Data set Name ---COPY TO: --MU00.@FPA2175.intermediary99999  DCB=(HCFA1.MODEL,BLKSIZE=2400,LRECL=2400,RECFM=FB)  Data set Name ---RUN JOB:  --MU00.@FPA2175.CLIST(intermediary99999)  20.3 - Additional Payment Amounts for Hospitals with Disproportionate Share of Low -Income Patients  (Rev. 2393, Issued: 01 -25-12, Effective: 10-01-11, Implementation: 07-02-12)  The Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985, (Public Law: 99- 272), provides for an additional payment to an urban hospital of 100 or more beds that serves a disproportionate share of low-income patients.   Adjustments are made in the Federal portion of the operating cost DRG payment to increase payments to hospitals serving a disproportionate share of low- income patients.  The additional payment equals the Federal portion of the operating cost DRG payment and outlier payments, but excludes any additional payments for the costs of indirect medical education multiplied by an adjustment percentage.  If a hospital meets the disproportionate share hospital (DSH) definition, an additional operating cost payment will be made for discharges occurring on or after May 1, 1986.  The DSH adjustment is applied only to the Federal portion of the operating cost DRG payment (including outlier payments).  It is basically a year-end lump sum adjustment.  However, the A/B MAC (A) will identify hospitals that are eligible to receive the DSH adjustment and make interim payments subject to a year -end settlement based upon the hospital's DSH percentage for the cost reporting period.  The DRG payment a hospital receives includes the interim operating cost DSH payment and an interim operating indirect medical education adjustment.  For services on or after October 1, 1997, the DSH percentage is not applied to outlier payments.  The Supplemental Security Income (SSI)/Medicare Beneficiary Data for IPPS hospitals is located at the following CMS web address:  https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/AcuteInpatientPPS/dsh.html  The data is used for settlement purposes for hospitals.   Note that CMS issues a Recurring Update Notification prior to the Federal Fiscal Year beginning date to provide contractors with the updated SSI file information.  A. - Regular Calculation of DSH Percentage   The operating DSH percentage is the sum of:   The percentage of the hospital's total Medicare Part A patient days attributable to Medicare patients who are also SSI recipients (this percentage will be supplied to the A/B MAC (A) by CMS).  Since the SSI/Medicare percentages are determined by CMS on a fiscal year basis, hospitals will be afforded the option (for settlement purposes) of determining their SSI/Medicare percentage based upon data from their own cost reporting period.  I f a hospital avails itself of this option, it must furnish its FI, in a manner and format prescribed by CMS, data on its Medicare patients for the cost reporting period.  CMS will match these data to data supplied by SSA to determine the patients dually entitled to Medicare Part A and SSI for the hospital's cost reporting period.  The hospital bears the full cost of this process, including the cost of verification by SSA.