California Code of Regulations › Title 8 - Industrial Relations › Division 1 - Department of Industrial Relations › Chapter 4.5 - Division of Workers' Compensation › Subchapter 1 - Administrative Director-Administrative Rules › Article 5.3 - Official Medical Fee Schedule › Section 9789.37 - DWC Form 15 Election for High Cost Outlier

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
State of California
Department of Industrial Relations
DIVISION OF WORKERS' COMPENSATION
ELECTION FOR HIGH COST OUTLIER
Labor Code §
											5307.1; Title
						8, California Code of Regulations §
											9789.37
This Section
						9789.37 is inapplicable for dates
						of service on or after September 1, 2014.
For the 12 month period commencing on April 1,
						20___.
___________________________
This Election is filed with the Administrative Director
						pursuant to Labor Code Section
						5307.1, and
						Title 8, California Code of Regulations Section
						9789.33. A provider who elects to
						participate in the alternative payment methodology for high cost outlier cases
						under Section
						9789.33, subdivision (b) in lieu of
						the maximum allowable fees set forth under Section
						9789.33 subdivision (a), shall file
						this form by March 1 of each year providing the requested information to the
						Administrative Director. The maximum allowable fees applicable to a facility
						that does not file a timely election satisfying the requirements set forth in
						Section 9789.33, subdivision (b), shall be
						determined under subdivision (a).
___________________________
1. PROVIDER'S NAME:
					 ___________________________
2.
					 OSHPD FACILITY NUMBER: ___________________________
3. MEDICARE PROVIDER NUMBER:
					 ___________________________
4.
					 CONTACT PERSON AND PHONE NUMBER: ___________________________
___________________________
Hospital Outpatient Department Cost-to-Charge
						Ratio
Pursuant to Section
						9789.33(c)(4), the
						cost-to-charge ratio applicable to a hospital outpatient department
						participating in the Medicare program shall be the hospital's cost-to-charge
						ratio used by the Medicare fiscal intermediary to determine high cost outlier
						payments under 42 CFR
						419.43(d). List below the
						cost-to-charge ratio being used by the intermediary for services furnished on
						February 15 of the year this election is filed:
5. Cost-to-charge ratio
					 ___________________________
___________________________
___________________________
Signature and
								  Title
Date
___________________________
Ambulatory Surgical Center (ASC) Cost-to-Charge
						Ratio
Pursuant to Section
						9789.33(c)(5), the
						cost-to-charge ratio applicable to an ambulatory surgery center shall be the
						ratio of the facility's total operating costs to total gross charges during the
						preceding calendar year. Total gross charges is defined as the facility's total
						usual and customary charges to patients and third-party payers before
						reductions for contractual allowances, bad debts, courtesy allowances and
						charity care.
6. Provide:
(a) The facility's total operating costs
					 during the preceding calendar year__________
(b) The facility's total gross charges during
					 the preceding calendar year __________
(c) Provide county where facility is
					 located__________