California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 3 - Health Care Services › Article 7.5 - HOSPITAL INPATIENT SERVICES REIMBURSEMENT SECTION › Section 51550 - Administrative Adjustment Process

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) A provider may request an AA to the ARPDL
					 or PGRPDL established for that provider if the provider's cost based allowable
					 reimbursement for the settlement fiscal period as defined by the lower of
					 Sections 51546(a)(1) and
					 (a)(2), exceeds or are expected to exceed the
					 PIRL by over $100. Expected to exceed only refers to the settlement period
					 being issued and not any future settlement fiscal periods. The burden shall be
					 on the provider to estimate, using the PIRL settlement information provided by
					 the Department and any other information they may have, if they will expect to
					 exceed the PIRL by over $100.
(b)
					 Items that are not subject to an AA or appeal include the following:
(1) The use of Medicare standards and
					 principles of reimbursement.
(2)
					 The reimbursement amounts determined in Section
					 51546(a)(1) and
					 (a)(2).
(3) The method for determining the
					 IPI.
(4) The use of all-inclusive
					 reimbursement rates.
(5) The use of
					 a volume adjustment formula.
(6)
					 Disproportionate share payments (these are not reduced by application of the
					 PIRL).
(7) Data reported on the
					 cost report which has been audited or reviewed by the Department are considered
					 true and correct pursuant to W&I Code Section
					 14170. Data that was incorrectly
					 transferred from the providers' Medi-Cal cost or audit report and used to
					 calculate the MIRL is subject to appeal.
(8) The methodology used to calculate the
					 interim rate.
(9) Any prior fiscal
					 period issues.
(10) Higher costs
					 due to low occupancy.
(11) Items
					 not reimbursed as part of the Medi-Cal cost report process as determined in
					 Section 51546(a)(1) and
					 (a)(2).
(12) Increased costs. Only the cause for the
					 increased costs may be appealable, and then only if it is otherwise an
					 appealable item.
(13) Any issue
					 raised in a previous formal appeal for which a decision was made by the
					 Department for the same provider. The only exception is to incorporate into the
					 settlement fiscal period PIRL the prior decision in the same manner as it was
					 previously decided by the Department. These only include decisions made for
					 FPEs affected by Sections
					 51545 through
					 51557. This does not include
					 issues withdrawn by the provider and thus not determined on their merits in the
					 formal decision.
(14) Increases in
					 average length of stay.
(15)
					 Changes in the Cost-Based Reimbursement System as determined under Section
					 51546(a)(1) and
					 (a)(2).
(16) Increased costs incurred by entering
					 into a contract which did not contain reasonable cost increase
					 limitations.
(17) Increases due to
					 increased costs or charges of a related party.
(18) Any issues involving labor cost
					 increases except for those allowed in Section
					 51551(b).
(19) New services.