evekhm/cms_iom_500 huggingface dataset:
(Medicare Claims Processing Manual)
Regardless of the type of allowable Medicaid da y, the hospit al bears the burden of proof and must ver ify with the  State that the patient was eligible unde r one of the allowable cat egories during e ach day of the patient's stay.  The hospit al is responsible  for and must pr ovide  adequate documentation to subst antiate the numbe r of Medicaid d ays claimed. Days for patients th at can not be  verified by State records to ha ve fallen within a  period wherein the  patient was eligible for Medicaid c annot be  counted.  Types of Days Included/Excluded in the  Medicare DSH Adjustm ent Calculation
(Medicare Claims Processing Manual)
Types of Days Included/Excluded in the  Medicare DSH Adjustm ent Calculation  Type of Day Description  Eligible Title  XIX Day General Assist ance Patient Days Days for patients covered und er a State-only (or county-only) general assistance program (whether or not a ny payment is a vailable for health care services unde r the program).  These patients are not M edicaid-eligible under the State plan No Other State-Only Health Program Patient Days Days for patients covered und er a State-only health program.  Th ese patients ar e not M edicaid-eligible under the State plan No Charity Care Patient Days Days for patients not eligible  for Medicaid or any other third-party payer, and claimed as uncompe nsated care by a hospit al.  These patients are not Medicaid-eligible under the State plan. No Actual 1902 (r)(2) and 1931( b) Days Days for patients eligible under a State plan based on a 1902 (r)(2) or 1931( b) election.  The se patients are Medicaid-eligible unde r the Title XIX State plan unde r the authority of these provisions, whi ch is e xercis ed by the State in the  context of the approved State plan. Yes Type of Day Description  Eligible Title  XIX Day Medicaid Optiona l Targeted Low- Income Children (CHIP-related) Days Days for patients who are Title  XIX-eligible and who m eet the definition  of "optiona l targeted low -income children" under 1905(u)(2) .  The difference between the se children and othe r Title  XIX children is the  enhanced FMAP rate available to the  State.  Th ese children are fully Medicaid-eligible unde r the State plan. Yes Separate CHIP Days Days for patients who are eligible for benefits under a non-Medicaid State program furnishi ng child health a ssistance to targeted low -income children. Th ese children are, by definition, not M edicaid-eligible under    No.  140.2.5.4 - Teaching Status Adjustment (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)
(Medicare Claims Processing Manual)
No.  140.2.5.4 - Teaching Status Adjustment (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  The teachi ng status adjustment is a  facili ty level adjustm ent made to the  Federal per discharge base rate to account f or the higher indirect operatin g costs experienced b y facilitie s that participate in graduate medical education.  The  adjustm ent is m ade on a c laim basis as an interim pa yment, with f inal payment in full for the cost reporting period m ade through the  cost report.  Any difference between the  interim payments and the  actu al teachi ng status adjustm ent amount comput ed in the  cost re port are adjust ed through lump sum payments/recoupm ents whe n the  cost re port is filed and later settled.  The  adjustm ent is b ased on the  IRFs teaching variable, which is the ratio of  the number of F TE re sidents training in the IRF (subj ect to the  FTE re sident ca p descr ibed belo w) to the IR Fs aver age daily ce nsus (ADC).  140.2. 5.4.1 - FTE Re sident Cap (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  There is a  cap on the nu mber of F TE re sidents tha t may be counted for purpose s of calcula ting the teaching adjustment, not the numb er of re sidents te aching institutions can hire or t rain. The F TE resident cap is id entical in fr eestanding teaching re habilitation hospita ls and in distinc t part rehabilitation units wi th GME p rogra ms. The cap is the number of F TE re sidents that trained in the IRF during a base year.
(Medicare Claims Processing Manual)
An IRFs FTE resident cap is det ermined based on the f inal settlement of the IR Fs most recent cost re porting period ending on or bef ore Nove mber 15, 2004. IRF s that first began training re sidents af ter Nove mber 15, 2004 will initially receive an F TE cap of z ero. The FTE caps for new IRFs (a s well as existing IRF s) that start training re sidents in a  new GME p rogram (as defined in 413.79(1)) may be subsequently adjusted in accordanc e with the  policie s that are being applied in the IPF PPS (a s described in 412.424(d)(1)( iii)(B )(2)), which in turn are made in accordance with the  policie s described in 42 CFR 413.79(e) .  For other types of Medic are provid ers (including long-ter m care hospita ls) that have been training re sidents and are curre ntly conv erting to IRFs, the f iscal inter mediary will determine  an F TE re sident cap for purposes of the IRF teaching status a djustment, appli cable beginning with the new I RFs payments under the IRF PPS based on the F TE count of re sidents durin g the  predecessor  facilitys most recent cost repor ting period ending on or bef ore No vember 15, 2004.  If the predece ssor facility did not begin training residents until af ter No vember 15, 2004, the fac ility would initially receive an F TE cap of zero.  The F TE caps for new IRF s (as well as existing IRF s) that start training re sident s in a ne w GME prog ram (as def ined in 413.79(1)), may be subsequently adjusted in accordance with the  policie s that are being applie d in the  IPF PPS (a s described in 412.424(d)(1)( iii)(B )(2)), which in turn are made in accordance with the  policie s described in 42 CFR 413.79(e) .
(Medicare Claims Processing Manual)
Once establish ed, the FT E resident cap for the t eaching status adjustme nt for the new IR F will be  subj ect to the  same rules and adjustme nts as any IR Fs FTE re sident cap.  CMS  will monitor  this policy closely to ensure tha t it is not b eing inappropriatel y manipulated.  IRFs are not per mitte d to aggregate the F TE re sident caps used to compute the IRF PPS teaching status adjustme nt through a ffiliation agr eements. Re sidents with l ess than full- time status and re sidents f loating through the re habilitation hospital or unit for le ss than a full year are counted in proportion to the time  they spend in the ir assignment with the  IRF (for example, a re sident on a full- time, 3-month rotation to the IRF would be  counted a s 0.25 F TEs for purpose s of counting re sidents to calcula te the ra tio). No FT E resident time counted for purpose s of the I PPS I ME adjustment is allowed to be counted for purpose s of the t eaching status adjustment for the IRF PPS.  The denomina tor used to cal culate the teachi ng status adjustm ent unde r the IRF PPS  is the IRFs average daily census (ADC ) from the  current cost re porting period. If a rehabilita tion hospit al or unit ha s mo re FTE residents in a  given year than in the  base year (the base year being used to establish the  cap) payments ar e based on the  lower number (the cap amount)  in th at year. If a rehabilita tion hospit al or unit w ere to ha ve fewer FTE residents in a  given year than in the  base year (that is, fe wer residents th an its FTE resident cap ) an adjustm ent in pa yments in th at year is based on the  lower numbe r (the actual numbe r of FTE residents the  facili ty hires and trains).
(Medicare Claims Processing Manual)
Effective for cost reporting periods beginning on or after October 1, 2011, the IRF FTE resident caps may be temporarily adjusted to reflect interns and residents added because of another IRFs closure or the closure of another IRFs residency training program.  An IRF is only eligible for the temporary cap adjustment if training the additional interns and residents would cause the IRF to exceed its FTE resident cap.  In addition, an IRF that closes a medical residency training program must agree to tempora rily reduce its FTE cap before other IRFs can receive temporary adjustments to their caps for training the IRFs interns and residents.  IRFs may qualify for the temporary cap adjustment for cost reporting periods beginning on or after October 1, 2011 if t hey are already training interns and residents displaced by IRF closures or residency training program closures that occurred prior to October 1, 2011.  140.2.5.5 - Outliers  (Rev. 2673, Issued: 03 -14-13, Effective: 04 -22-13, Implementation: 04- 22-13)  Section 1886(j)(4) of the Act provides the Secretary with the authority to make payments in addition to the basic IRF prospective payments for cases incurring extraordinarily high cost.  A case qualifies for outlier payment if the estimated cost of the cas e exceeds the adjusted outlier threshold.  CMS calculates the adjusted outlier threshold by adding the IRF PPS payment for the case (that is, the CMG payment adjusted by all of the relevant facility -level adjustments) and the adjusted threshold amount (als o adjusted by all of the relevant facility -level adjustments).  Then, CMS calculates the estimated cost of the case by multiplying the IRFs overall cost -to-charge ratio (CCR) by the Medicare allowable covered charge. If the estimated cost of the case is h igher than the adjusted outlier threshold, CMS makes an outlier payment for the case equal to 80 percent of the difference between the estimated cost of the case and the outlier threshold.   The adjusted threshold amount and upper threshold CCR are set forth annually in the IRF PPS notices published in the Federal Register.
(Medicare Claims Processing Manual)
The adjusted threshold amount and upper threshold CCR are set forth annually in the IRF PPS notices published in the Federal Register.   140.2.6 - Cost -to-Charge Ratios  (Rev. 2323, Issued: 10- 26-11, Effective: 11 -28-11, Implementation: 11- 28-11)  For discharges beginning on and after January 1, 2002 thru September 30, 2003, the Medicare contractor shall use the instructions for calculating the CCR for purposes of determining outlier payments under the IRF PPS set forth in Transmittal A -01-131.   For discharges beginning on or after October 1, 2003, the Medicare contractor shall use a CCR from the most recent tentative settled cost report or the most recent settled cost report (whichever is the later period), specific to freestanding IRFs or for IR Fs that are distinct part units of acute care hospitals in accordance with the formulas set forth below.   Effective October 1, 2003, if an IRFs CCR is above the applicable ceiling set forth annually in the IRF PPS notices published in the Federal Register it is considered to be statistically inaccurate. As a result, CMS will assign the IRF an appropriate national average CCR. CMS does not use a lower threshold; an IRF will receive their actual CCR, no matter how low their ratio falls.   The IRF PPS covers operating and capital -related costs and excludes medical education and nurse anesthetist costs paid for on a reasonable cost basis. Therefore, total Medicare charges for IRFs will consist of the sum of the inpatient routine charges and t he sum of inpatient ancillary charges (including capital). Total Medicare costs will consist of the sum of inpatient routine costs (net of private room differential and swingbed) plus the sum of ancillary costs plus capital -related pass -through costs only.
(Medicare Claims Processing Manual)
The provider specific file (PSF) contains a field for the operating CCR (Field 25; file position 102- 105) and for the capital CCR (Field 42; file position 203- 206). Because the CCR computed for the IRF PPS includes routine, ancillary, and capital costs, the CCR for freestanding IRFs, units, and new providers described below will be entered on the provider specific file only in field 25; file position 102- 105. Field 42; file position 203- 206 of the provider specific file must be zero -filled.   The Medicare contractor shall continue to update the IRFs CCR each time a more recent cost report is settled (either final or tentative). Revised CCRs shall be entered into the PSF not later than 30 days after the date of the latest settlement used in calculating the CCR.   A. - Calculating Medicare CCRs for Freestanding IRFs   1) Identify total Medicare costs from Worksheet D -1, Part II, line 49 minus (Worksheet D, Part III, col. 8, lines 25 through 30 plus Worksheet D, Part IV, col. 7, line 101).   2) Identify total Medicare charges (the sum of routine and ancillary charges), from Worksheet D -4, Column 2, the sum of lines 25 through 30 and line 103 from the cost report; where possible, these charges should be confirmed with the PS&R data.   3) Divide the Medicare costs by the Medicare charges to compute the CCR.   B. - Calculating Medicare CCRs for IRF Distinct Part Units   1) Identify total Medicare costs from Worksheet D -1, Part II, line 49 minus (Worksheet D, Part III, col. 8, line 31 plus Worksheet D, Part IV, col. 7, line 101).   2) Identify total Medicare charges (the sum of routine and ancillary charges) from Worksheet D -4, Column 2, line 31 plus line 103 from the cost report; where possible, these charges should be confirmed with the PS&R data.   3) Divide the Medicare costs by the Medicare charges to compute the CCR.   All references to Worksheets and specific line numbers shall correspond with the sub-provider identified as the IRF unit that has the letter "T" or R in the third position of the Medicare provider number.
(Medicare Claims Processing Manual)
All references to Worksheets and specific line numbers shall correspond with the sub-provider identified as the IRF unit that has the letter "T" or R in the third position of the Medicare provider number.   C. - Calculating Medicare CCRs for New IRFs   In the case of a New IRF unit (defined in 42 C.F.R. 412.30) or a New Inpatient Rehabilitation Hospital (defined as a hospital that has never entered into a provider agreement with the Secretary), the Medicare contractor shall use a national average CCR based on the facility location of either urban or rural. The national average CCRs applicable to IRFs shall be found in each years annual notice of prospective payment rates published in the Federal Register.   The national average CCR will be used until the IRFs actual CCR can be computed using the first tentative settled or final settled cost report data, which will then be used for the subsequent cost report periods.   We NOTE, the policies in  E and F below can be applied as an alternative to the national average CCR.   For those IRFs assigned the national average CCR, the CCR must be updated every October 1 based on the latest national average CCRs published in each years IRF PPS annual notice of prospective payment rates until the IRF is assigned a CCR based on the latest tentative or final settled cost report or a CCR based on the policies of part E and F of this section.   D. - Mergers, Conversion and Errors with CCRs   Effective April 1, 2011, in the case of a merger, the Medicare contractor shall use the CCR from the IRF with the surviving provider number. If a new provider number is issued (i.e., a new provider agreement is signed because the new owner refused assignme nt of the existing provider agreement), the Medicare contractor shall use the national CCR based on the facility location of either urban or rural.   When errors related to CCRs and/or outlier payments are discovered, Medicare contractors shall contact the CMS Central Office to seek guidance. Likewise, when a cost report is reopened after final settlement and as a result of this reopening there is a change to the CCR; Medicare contractors should contact the CMS Central Office for further instructions.   E. - Alternative CCRs
(Medicare Claims Processing Manual)
The CMS may direct the Medicare contractor to use an alternative CCR to the CCR from the later of the latest settled cost report or latest tentative settled cost report, if it believes this will result in a more accurate CCR. In addition, if the Medicare c ontractor finds evidence that using data from the latest settled or tentatively settled cost report would not result in the most accurate CCR, the Medicare contractor should contact the CMS Regional Office and CMS Central Office to seek approval to use a C CR based on alternative data. For example, CCRs may be revised more often if a change in an IRFs operations occurs which materially affects the IRFs costs and/or charges. Notification to the CMS Central Office shall be sent to the mailing address or emai l address provided in Part (f) below. The CMS Regional Office, in conjunction with CMS Central Office, will approve or deny any request by the Medicare contractor for use of an alternative CCR. Revised CCRs will be applied prospectively to all IRF PPS claims processed after the update.  F. - Request for Use of a Different CCR by the IRF   Also, an IRF will have the opportunity to request that a different CCR be applied in the event it believes the CCR being applied is inaccurate. The IRF is required to present substantial evidence supporting its request. Such evidence should include documentation regarding its costs and charges that demonstrate its claim that an alternative ratio is more accurate. After the Medicare contractor has evaluated the evidence presented by the IRF, the Medicare contractor notifies the CMS Regional Office and CMS Central Office of such a request. The CMS Regional Office, in conjunction with CMS Central Office, will approve or deny any request by the IRF for use of a different CCR. Medicare contractors shall send requests to the CMS Central Office at the following address or email address:   CMS  C/O Division of Institutional Post Acute Care  7500 Security Blvd  Mail Stop C5 -06-27  Baltimore, MD 21244   irf_outlier_reconciliation@cms.hhs.gov   Revised CCRs will be applied prospectively to all IRF PPS claims processed after the update.   G. - Notification to Facilities Under the IRF PPS
(Medicare Claims Processing Manual)
Revised CCRs will be applied prospectively to all IRF PPS claims processed after the update.   G. - Notification to Facilities Under the IRF PPS   The Medicare contractor shall notify an IRF whenever they make a change to its CCR. When a CCR is changed as a result of a tentative settlement or a final settlement, the change to the CCR should be included in the notice that is issued to each provider after a tentative or final settlement is completed.   H. - Maintaining a History of CCRs and Other Fields in the Provider Specific File   When recalculating claims due to outlier reconciliation, Medicare contractors shall maintain an accurate history of certain fields in the PSF. This history is necessary to ensure that claims already processed (from prior cost reporting periods that have al ready been settled) will not be subject to a duplicate systems adjustment in the event that claims need to be reprocessed. As a result, the following fields in the PSF can only be altered on a prospective basis: 21 - Case Mix Adjusted Cost Per Discharge, 24 - Bed Size, 25 -Operating Cost to Charge Ratio, 27 - SSI Ratio, - 28 -Medicaid Ratio and 49 - Capital IME. A separate history outside of the PSF is not necessary. The only instances a Medicare contractor retroactively changes a field in the PSF is to update t he CCR when using the FISS Lump Sum Utility for outlier reconciliation or otherwise specified by the CMS Regional Office or Central Office.   140.2.7 - Use of a National Average Cost -to-Charge Ratio  (Rev.  2111, Issued: 12- 03-10, Effective: 04 -01-11, Implementation: 04- 04-11)  A national average CCR based on the facility location of either rural or urban is applied in the following situations:    New IRFs that have not yet submitted their first Medicare cost report.    IRFs whose overall CCR is in excess of the national CCR ceiling, as set forth annually in the IRF PPS notices published in the Federal Register.    Other IRFs for which accurate data to calculate an overall CCR are not available.   However, the policies of 140.2.6 part E and F can be applied as an alternative to the national average CCR.   The national urban and rural CCRs for IRFs are set forth annually in the Federal Register.
(Medicare Claims Processing Manual)
However, the policies of 140.2.6 part E and F can be applied as an alternative to the national average CCR.   The national urban and rural CCRs for IRFs are set forth annually in the Federal Register.   140.2.8 - Reconciling Outlier Payments for IRFs  (Rev. 2111, Issued: 12- 03-10, Effective: 04 -01-11, Implementation: 04- 04-11)  A. - General   For discharges occurring in cost reporting periods beginning on or after October 1, 2003, Medicare contractors are to reconcile IRF PPS outlier payments at the time of cost report final settlement if:   1) Actual CCR is found to be plus or minus 10 percentage points from the CCR used during that time period to make outlier payments, and   2) Outlier payments exceed $500,000 in that cost reporting period.   The return codes from the PRICER software may be used to identify the cases for which outlier payments were made in a cost reporting period.   In the event that these criteria do not identify facilities that are being overpaid (or underpaid) significantly for outliers, then, based on an analysis of the facilitys most recent cost and charge data that indicates that the CCR for those facilities ar e significantly inaccurate, Medicare contractors and the CMS Central Office also have the administrative discretion to reconcile cost reports of those IRFs. However, Medicare contractors must seek approval from the CMS Regional Office and CMS Central Office in the event they intend to reconcile outlier payments for an IRF that does not meet the above -specified criteria.   To determine if an IRF meets the criteria for outlier reconciliation, the Medicare contractor shall perform the following steps: (1) incorporate all the adjustments from the cost report, (2) run the cost report, (3) calculate the revised CCR and (4) comput e the actual CCR prior to issuing a Notice of Program Reimbursement (NPR). If the criteria are not met, the cost report can be finalized. If the criteria are met, Medicare contractors shall follow the instructions in 140.2.10. The NPR cannot be issued nor  can the cost report be finalized until outlier reconciliation is complete.