CMS-10398 #24 MACFIN_prtf-upl-template

[Medicaid] Generic Clearance for Medicaid and CHIP State Plan, Waiver, and Program Submissions (CMS-10398)

X MACFIN_prtf-upl-template.xlsx

#24 (Revision): Medicaid Accountability – Upper Payment Limits for Clinics, Physician Services, ICF/IID, PRTFs, and IMDs

OMB: 0938-1148

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1148 can be found here:

Document [xlsx]

Download: xlsx | pdf

Overview

State Attestation
Overview & Instructions
Data Dictionary
Required State Input – PRTF
PRTF
UPL Demonstration Summary
Optional_Sheet_1
Optional_Sheet_2
Optional_Sheet_3
Optional_Sheet_4
Optional_Sheet_5
Optional_Sheet_6
Optional_Sheet_7
Optional_Sheet_8
Optional_Sheet_9
Optional_Sheet_10
Optional_Sheet_11
Optional_Sheet_12
Optional_Sheet_13
Optional_Sheet_14
Optional_Sheet_15

Sheet 1: State Attestation

Upper Payment Limit Demonstration Report		This cell is intentionally left blank
1. I HEREBY CERTIFY that I have read this certification statement and that I have examined the accompanying electronically filed and/or manually submitted Upper Payment Limit demonstration
report prepared by:
(please insert the state Medicaid official (or other person who prepared this UPL demonstration report) Name(s), title(s), and Contact Number(s))
for the report period beginning (MM/DD/YYYY):
and ending (MM/DD/YYYY):
I further certify that, to the best of my knowledge and belief, this report is true, accurate, and complete, and except as noted, have been prepared from the books and records of the providers and Medicaid agency in accordance with applicable instructions. I further certify that I am familiar with the laws and regulations regarding the provision of health care services, and that the services identified in this Upper Payment Limit demonstration report are provided in compliance with such laws and regulations.
2. I certify that the costs reported in this Upper Payment Limit demonstration represent a reasonable estimate of the amount that Medicare would pay for these Medicaid services, consistent with 45 CFR part 75 and 2 CFR part 200, with expenditure/cost data trended forward based on historical data.
3. State and/or local funds are available and will be used to pay for total computable allowable expenditures included in this statement, and the source(s) of such state and/or local funds are in accordance with all applicable federal requirements for the non-federal share of expenditures (including that the funds are not Federal funds in origin or are Federal funds authorized by Federal law to be used to match other Federal funds, and that the federal funds received to match the claimed expenditures will not be used to meet matching requirements under other Federally funded programs).
4. I understand that this information may be used as a basis for claims for federal funds, and that falsification and concealment of a material fact may be prosecuted under federal or state civil or criminal law.
5. I certify that, to the best of my knowledge and belief, all necessary information has been provided to support the determination of the UPL amount, including supplemental materials used to complete the template. I certify that, to the best of my knowledge and belief, none of the calculations or formulas in the template have been changed, and the most recent version of the template has been used for this submission.
6. I certify that, to the best of my knowledge and belief, the structure of this OMB approved and locked template has not been altered in any way, all applicable instructions in the guidelines and directions have been followed in completing this UPL demonstration, and the template has been completed consistent with the definitions in the data dictionary.
7. I am the officer authorized by the relevant state government agency to submit this form and I have made a good faith effort to ensure that all information reported is true and accurate.
Electronic Signature:
Title & Contact Information:
End of Worksheet

Sheet 2: Overview & Instructions

This worksheet is for providing an overview and instructions for the Psychiatric Residential Treatment Facilities UPL Template. Use the arrow keys to read through the document.

Overview
States are required to demonstrate, and Centers for Medicare and Medicaid Services (CMS) has accepted a reasonable estimate of the Upper Payment Limit (UPL) based on a comparison of Medicaid (MCD) payments to equivalent Medicare (MCR) payment, Medicaid cost using Medicare principles, or customary/prevailing charges. CMS has developed guidance documents to help states meet statutory and regulatory requirements that can be downloaded from:

CMS Accountability Guidance

CMS is also introducing templates specific to each service type, which have been developed to assist states in meeting UPL requirements and increase comparability across states. This workbook contains templates for the Psychiatric Residential Treatment Facilities (PRTF) UPL demonstrations.

For each facility, please complete the "Required State Input – PRTF" tab. Please ensure the top section of the input tab in the template is completed, which includes the state, the start date for the demonstration, and the end date for the demonstration. This is used to ensure that there are no gaps between yearly submissions.

If a cell has a red background, critical data for that variable is missing or invalid. Once the data is filled in with valid data for the specified cell, the template will remove the red color from the cell. For details about the valid data format and valid values for each variable, please see the Data Dictionary tab.

States may not enter data into the tabs labeled "PRTF" and "Total_Adjusted_UPL_Gap." The template calculates the content on these tabs automatically based on the data entered on the input tab. They are included as a reference only.

States may use the worksheet tabs labeled "Optional_Sheet_1," "Optional_Sheet_2," etc. to include supplementary data needed to calculate the content for the "Required State Input – PRTF" tab. These sheets are optional. If you choose to enter data in the optional worksheet tabs, please provide a brief explanation of the content at the top of the worksheet.

States may apply different UPL formulas for state government owned or operated facilities, non-state government owned or operated facilities and private facilities; however, the formula should be consistently applied to each provider within the category. Additionally, each facility should only be included in one type of UPL demonstration. In filling out the input tabs within this template, data for each individual provider should be included on one separate row. Additionally, all supplemental payments made by the state should be reported for each individual provider and reported separate from regular Medicaid payments. There may be instances where a variable is not applicable to your UPL calculation. Please leave these variables blank unless otherwise noted in the data dictionary.

Information Requested:
CMS requests the following information for each PRTF:
- Demonstration Information asks for basic information such as the state, demonstration rate year, service type (PRTF), and demonstration type (cost, charges, or payments)
- Provider Information asks for provider identification numbers and names for each facility included, and the ownership category type (private, non-state government owned, state-government owned)
- Cost or Charge Data asks for base year data relevant to the calculation of the UPL
- Medicaid Payment and Utilization Data for Base Period asks for Medicaid utilization data used to calculate the UPL, as well as Medicaid payment data that is used to determine whether or not the state has made payments in excess of the UPL
- Medicaid Payments Inflated to Demonstration Year asks for inflationary or volume adjustment data that are made by the state to reflect changes in the Medicaid program that have occurred between the base and current rate year periods

- UPL Calculation & Inflation to Demonstration Year instructs the state to calculate the UPL and asks for inflationary adjustments to appropriately trend UPL data from the base to the current rate year
- Adjustments to UPL asks for other adjustments to the UPL that are not included in the UPL calculation
- Calculation of UPL Gap instructs the state to calculate the UPL gap for each facility by subtracting (adjusted/inflated) Medicaid payments from the calculated UPL

Payment and Cost Data: Enter to the nearest dollar (i.e. $1,234,567.89 should be entered as $1,234,568)
Proportion and Percentage Data: Enter with no more than four decimal places (i.e., 0.12345 should be entered as 0.1235)

CMS has developed an instructional document for Psychiatric Residential Treatment Facilities to help states create their UPL demonstration. This document can be downloaded from:

CMS UPL Instructions for Other Inpatient and Outpatient Services

Detailed descriptions for each variable are provided in the next sheet labeled "Data Dictionary." A hypothetical PRTF's data has also been entered for each template to provide guidance and formulas regarding the data requested for each column.

PRA Disclosure Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1148. The time required to complete this information collection is estimated to average 40 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

End of Worksheet

Sheet 3: Data Dictionary

This worksheet includes a data dictionary to assist in completing the Psychiatric Residential Treatment Facilities Template. The table includes the variable number, required variable format, a short description of the input variable, a longer and more detailed description of the variable, and a key for which of the template tabs the variable is used in. Use the arrow keys to read through the document.
Table 1. CMS UPL Psychiatric Residential Treatment Facilities Template Data Dictionary
Variable numbering scheme is used for internal identification of each variable and is not meant to be presented in numerical order
Variable Number	Variable Designation	Variable Format	Short Description	Long Description	Variable Status
001	Required	2-character text	State	2-character state ID (e.g., Maryland = MD)	0: Variables Included in PRTF Template
002	Required	Date [MM/DD/YYYY]	Demonstration Begin Date	Start date of the State demonstration rate year	0: Variables Included in PRTF Template
003	Required	Date [MM/DD/YYYY]	Demonstration End Date	End date of the State demonstration rate year	0: Variables Included in PRTF Template
100	Required	2-character text	State	2-character state ID (e.g., Maryland = MD)	0: Variables Included in PRTF Template
101	Required	4-digit number	State Demonstration Rate Year	State demonstration rate year YYYY (e.g., 2014)	0: Variables Included in PRTF Template
102	Required	4-character text	Service Type	Service type: PRTF = Psychiatric Residential Treatment Facilities	0: Variables Included in PRTF Template
103	Not Applicable to this Template (N/A)	N/A	N/A	N/A	N/A
104	Required	Text	Demonstration Type (Cost, Charge, Payment)	Demonstration type (Cost = Cost-based, Charge = Charge-based, Payment = Payment-based)	0: Variables Included in PRTF Template
105	Provide if Applicable (PIA)	Unspecified	Other State Provider ID Number	State provider ID number that is not a Medicaid (MCD) ID number (if applicable).	0: Variables Included in PRTF Template
106	N/A	N/A	N/A	N/A	N/A
107	Required	Unspecified	State-specific Provider ID (MCD ID)	Medicaid (MCD) ID number.	0: Variables Included in PRTF Template
108	Required	Text	Provider Name	Provider name	0: Variables Included in PRTF Template
109	PIA	10-11 digit number	National Provider ID (NPI)	National Provider Identification Number	0: Variables Included in PRTF Template
110	Required	Text	Ownership Category Type (Private, NSGO, SGO)	Ownership category type (private= private; NSGO= non-state government owned; SGO= state government owned).	0: Variables Included in PRTF Template
111	N/A	N/A	N/A	N/A	N/A
112	Required	6-digit number	MCR Certification Number (MCR ID)	Medicaid (MCD) ID number. In the instances where a facility is Not Medicare Certified (NMC), the state should enter "NMC."	0: Variables Included in PRTF Template
113-115	N/A	N/A	N/A	N/A	N/A
116	Provide if Applicable (PIA)	Text	Retrospective/Prospective Demonstration	An indicator that identifies the demonstration as retrospective or prospective. UPL is considered retrospective when it is submitted on or after the start of the demonstration period, and considered prospective if submitted prior to the start of the demonstration period.	0: Variables Included in PRTF Template
117	Provide if Applicable (PIA)	10-character text	State Plan Amendment (SPA) Number	The state plan amendment number associated with the demonstration submission. The expected format is: 2 letter state abbreviation-##-#### (for example, OR-19-0002).	0: Variables Included in PRTF Template
200.1	Required	Date [MM/DD/YYYY]	Begin Date for Charge, Cost, or Payment Data	Begin date of charge, cost, or payment data provided that are used to calculate the UPL.	0: Variables Included in PRTF Template
200.2	Required	Date [MM/DD/YYYY]	End Date for Charge, Cost, or Payment data	End date of charge, cost, or payment data provided that are used to calculate the UPL.	0: Variables Included in PRTF Template
201-212.2	N/A	N/A	N/A	N/A	N/A
212.3	Required	$ Amount	Adjustments to the Per Diem Charge, Cost, or Payment	Adjustments to per diem charge, cost, or payment.	0: Variables Included in PRTF Template
213-214	N/A	N/A	N/A	N/A	N/A
215	Calculated	$ Amount	Total Per Diem Charge, Cost, or Payment	Calculated as Per Diem Charge, Cost, or Payment (Variable 223) + Adjustments to Per Diem Charge, Cost, or Payment (Variable 212.3).	0: Variables Included in PRTF Template
216-222	N/A	N/A	N/A	N/A	N/A
223	Required	$ Amount	Per Diem Charge, Cost, or Payment	Per diem charge, cost, or payment amount used to calculate the UPL from the period specified in Variables 200.1 and 200.2.	0: Variables Included in PRTF Template
224-226	N/A	N/A	N/A	N/A	N/A
300.1	Required	Date [MM/DD/YYYY]	Time Period of MCD Days - Begin Date	Beginning date of base year Medicaid (MCD) days (note: should match cost or customary charge data period).	0: Variables Included in PRTF Template
300.2	Required	Date [MM/DD/YYYY]	Time Period of MCD Days - End Date	End date of base year Medicaid (MCD) days (note: should match cost or customary charge data period).	0: Variables Included in PRTF Template
301-306	N/A	N/A	N/A	N/A	N/A
307	PIA	Text	MCD Inflation Factor Type	Description of Medicaid (MCD) payment trend factor used to reflect changes in the Medicaid program between the base and current UPL Demonstration year periods (e.g., Market Basket). If the value for variable 308 is anything other than 1.0, then variable 307 should be populated with data.	0: Variables Included in PRTF Template
308	Required	Proportion	MCD Inflation Factor	Cumulative Medicaid (MCD) payment trend factor used to reflect changes in the Medicaid program between the base (midpoint of Variable 300.1 and Variable 300.2) and current UPL Demonstration year periods (note: 1.00 = no change) (use "mid-point to mid-point approach"). Values for this field should not be negative. A value less than 1 or greater than 1.04 for this field will trigger an error.	0: Variables Included in PRTF Template
309	Required	Proportion	Other Adjustment to MCD Payments	Cumulative other adjustment (e.g., volume adjustment) factor used to reflect changes in the Medicaid (MCD) program between the base (midpoint of variable 300.1 & variable 300.2) and current UPL Demonstration year periods (note: 1.00 = no change) (use "mid-point to mid-point approach"). Values of blank or zero will trigger an error for this field. Values for this field should not be negative.	0: Variables Included in PRTF Template
310	Required	Number	MCD Days	Medicaid (MCD) days from time period specified in Variables 300.1 and 300.2, used in calculating the UPL for the base period.	0: Variables Included in PRTF Template
311.1	Required	Date [MM/DD/YYYY]	Time Period of MCD Rates - Begin Date	Beginning date of Medicaid (MCD) rates used to determine total MCD payments for purposes of comparing to the UPL.	0: Variables Included in PRTF Template
311.2	Required	Date [MM/DD/YYYY]	Time Period of MCD Rates - End Date	End date of Medicaid (MCD) rates used to determine total MCD payments for purposes of comparing to the UPL.	0: Variables Included in PRTF Template
312	Required	$ Amount	MCD Base Payment Per Diem	Medicaid (MCD) base payments per diem applicable to the dates specified in Variables 311.1 and 311.2.	0: Variables Included in PRTF Template
313.1	Required	$ Amount	MCD Supplemental Payment Per Diem	Medicaid supplemental payments per diem associated with the UPL demonstration year. In the notes section the state should explain the type(s) of payment reported and the related amount(s). The state may not report DSH payments as supplemental payments.	0: Variables Included in PRTF Template
313.2	Required	$ Amount	MCD Supplemental Payment Per Diem - GME/Training	Medicaid supplemental payments per diem associated with the UPL demonstration year for GME (Graduate Medical Education). In the notes section the state should explain the type(s) of payment reported and the related amount(s). The state may not report DSH payments as supplemental payments.	0: Variables Included in PRTF Template
313.3	Required	$ Amount	MCD Supplemental Payment Per Diem - Other	Medicaid supplemental payments per diem associated with the UPL demonstration year. In the notes section the state should explain the type(s) of payment reported and the related amount(s). The state may not report DSH payments as supplemental payments.	0: Variables Included in PRTF Template
314.1	Required	$ Amount	Adjustment to MCD Per Diem #1	Adjustment to Medicaid (MCD) payments per diem (e.g., drugs, therapy, lab, radiology).	0: Variables Included in PRTF Template
314.2	Required	$ Amount	Adjustment to MCD Per Diem #2	Adjustment to Medicaid (MCD) payments per diem (e.g., drugs, therapy, lab, radiology).	0: Variables Included in PRTF Template
315	Calculated	$ Amount	Inflated and Adjusted MCD Payment Per Diem	Calculated as Total MCD Supplemental Payments Per Diem with Adjustments (Variable 317) + (MCD Base Payment Per Diem (Variable 312) * MCD Inflation Factor (Variable 308) * Other Adjustment to MCD Payments (Variable 309)).	0: Variables Included in PRTF Template
316	Calculated	$ Amount	Total MCD Payments	Calculated as Inflated and Adjusted MCD Payment Per Diem (Variable 315) * MCD Days (Variable 310).	0: Variables Included in PRTF Template
317	Calculated	$ Amount	Total MCD Supplemental Payments Per Diem with Adjustments	Calculated as MCD Supplemental Payment Per Diem (Variable 313.1) + Supplemental Payment GME/Training Per Diem (Variable 313.2) + Supplemental Payment Other Per Diem (Variable 313.3) + Adjustment to MCD Per Diem #1 (Variable 314.1) + Adjustment to MCD Per Diem #2 (Variable 314.2).	0: Variables Included in PRTF Template
318	N/A	N/A	N/A	N/A	N/A
400	Calculated	$ Amount	Inflated UPL Per Diem	Calculated as Total Per Diem Charge, Cost, or Payment (Variable 215) * UPL Inflation Factor (Variable 405).	0: Variables Included in PRTF Template
401	N/A	N/A	N/A	N/A	N/A
402	Required	$ Amount	Other Adjustments to the UPL Amount	Adjustments made to the UPL that are not otherwise accounted for in the UPL calculation (e.g., adjustments for managed care transition, ACA adjustments to the UPL). This field should only include values that specifically increase or decrease the UPL. These adjustments represent changes to the UPL prior to the calculation of the UPL gap. If the state provides this as an aggregate adjustment and does not have this information broken out by individual facilities, these adjustments should be distributed across all facilities as appropriate. Any adjustments made in this field must be properly documented and explained in the notes section. If not applicable, this variable should be populated with $0.	0: Variables Included in PRTF Template
403	Calculated	$ Amount	Adjusted MCR UPL Amount	Calculated as Inflated UPL Amount (Variable 406) + Other Adjustments to the UPL Amount (Variable 402). This calculated estimate represents the amount that Medicare would pay for Medicaid services.	0: Variables Included in PRTF Template
404	PIA	Text	UPL Inflation Factor Type	Description of cumulative trend factor used to inflate the Total Per Diem Charge, Cost, or Payment (Variable 215) from the base year to the UPL Demonstration year (e.g., Market Basket). If the value for variable 405 is anything other than 1.0, then variable 404 should be populated with data.	0: Variables Included in PRTF Template
405	Required	Proportion	UPL Inflation Factor	Cumulative trend factor used to inflate the Total Per Diem Charge, Cost, or Payment (Variable 215) Calculated MCD UPL Per Diem Amount from the base year (midpoint of Variable 200.1 and 200.2) to the UPL Demonstration year (note: 1.00 = no change) (use "mid-point to mid-point approach"). A value less than 1 or greater than 1.04 for this field will trigger an error.	0: Variables Included in PRTF Template
406	Calculated	$ Amount	Inflated UPL Amount	Calculated as Inflated UPL Per Diem (Variable 400) * MCD Days (Variable 310).	0: Variables Included in PRTF Template
407	Calculated	$ Amount	UPL Gap Amount	Calculated as Adjusted MCD UPL Amount (Variable 403) - Total MCD Payments (Variable 316).	0: Variables Included in PRTF Template
408	Required	$ Amount	Adjustment to the UPL Gap	Adjustments made to the UPL gap. For example, states may utilize this variable to report an anticipated reduction in payment during the UPL demonstration year. Any adjustments to the UPL gap should be distributed across all facilities as appropriate and the adjustments must be documented in the notes section. If not applicable, this variable should be populated with $0.	0: Variables Included in PRTF Template
409	Calculated	$ Amount	Adjusted UPL Gap	Calculated as UPL Gap Amount (Variable 407) + Adjustment to the UPL Gap (Variable 408).	0: Variables Included in PRTF Template
410-424	N/A	N/A	N/A	N/A	N/A
End of Worksheet

Sheet 4: Required State Input – PRTF

(Required)

State

[001]

(Required)

Demonstration
Begin Date

[002]

(Required)

Demonstration
End Date

[003]

(PIA)

Retrospective/ Prospective Demonstration

[116]

(PIA)

State Plan Amendment Number (SPA)

[117]

This cell is intentionally left blank

Data Validation Key

This cell is intentionally left blank

EXAMPLE

Grey Shading, White Italic Font: Field does not apply to Demonstration Type entered for row.

EXAMPLE

Yellow Shading, Black BOLD Font: Duplicate provider info values entered for 1) Elements 105, 112, 107, 108, or 2) Element 109

This cell is intentionally left blank

EXAMPLE

Red Shading only: Required field is left blank. Red Shading, White BOLD font: Invalid value entered in field.

This cell is intentionally left blank

Database
Description
&

Variable
Numbers

Demo Info:

(Required)

State

[100]

Demo Info:

(Required)

State
Demonstration
Rate Year

[101]

Demo Info:

(Required)

Service
Type

[102]

Demo Info:

(Required)

Demonstration
Type

[104]

Provider Info:

(PIA)

Other State
Provider ID
Number

[105]

Provider Info:

(PIA)

National
Provider ID
(NPI)

[109]

Provider Info:

(Required)

Medicare
Certification
Number
(Medicare ID)

[112]

Provider Info:

(Required)

State-specific
Provider ID
(Medicaid ID)

[107]

Provider Info:

(Required)

Provider Name

[108]

Provider Info:

(Required)

Ownership
Category
Type

[110]

Cost or Charge
Info:

(Required)

Begin Date for
Charge, Cost, or
Payment Data

[200.1]

Cost or Charge
Info:

(Required)

End Date for
Charge, Cost, or
Payment Data

[200.2]

Cost or Charge
Info:

(Required)

Per Diem
Charge, Cost,
or Payment

[223]

Cost or Charge
Info:

(Required)

Adjustments to
Per Diem Charge,
Cost, or Payment

[212.3]

MCD Info:

(Required)

Time Period of
Medicaid Days -
Begin Date

[300.1]

MCD Info:

(Required)

Time Period of
Medicaid Days -
End Date

[300.2]

MCD Info:

(Required)

Medicaid Days

[310]

MCD Info:

(Required)

Time Period of
Medicaid Rates -
Begin Date

[311.1]

MCD Info:

(Required)

Time Period of
Medicaid Rates -
End Date

[311.2]

MCD Info:

(Required)

Medicaid
Base
Payment Per Diem

[312]

MCD Info:

(Required)

Medicaid
Supplemental
Payment Per Diem

[313.1]

MCD Info:

(Required)

Medicaid
Supplemental
Payment Per Diem
(GME/Training)

[313.2]

MCD Info:

(Required)

Medicaid
Supplemental
Payment Per Diem
(Other)

[313.3]

MCD Info:

(Required)

Adjustment to
Medicaid
Per Diem #1

[314.1]

MCD Info:

(Required)

Adjustment to
Medicaid
Per Diem #2

[314.2]

MCD Inflated
Payment Info:

(PIA)

Medicaid
Inflation
Factor Type

[307]

MCD Inflated
Payment Info:

(Required)

Medicaid
Inflation
Factor

[308]

MCD Inflated
Payment Info:

(Required)

Other
Adjustment to
Medicaid
Payments

[309]

UPL Calc Info:

(PIA)

UPL Inflation
Factor Type

[404]

UPL Calc Info:

(Required)

UPL Inflation
Factor

[405]

UPL Adjustment
Info:

(Required)

Other
Adjustments to
the UPL Amount

[402]

UPL Gap
Info:

(Required)

Adjustment
to the
UPL Gap

[408]

No Data

End of Worksheet

Sheet 5: PRTF

(Required)

State

[001]

(Required)

Demonstration
Begin Date

[002]

(Required)

Demonstration
End Date

[003]

(PIA)

Retrospective/ Prospective Demonstration

[116]

(PIA)

State Plan Amendment Number (SPA)

[117]

This cell is intentionally left blank

Database
Description
&

Variable
Numbers

Demo Info:

(Required)

State

[100]

Demo Info:

(Required)

State
Demonstration
Rate Year

[101]

Demo Info:

(Required)

Service
Type

[102]

Demo Info:

(Required)

Demonstration
Type

[104]

Provider Info:

(PIA)

Other State
Provider ID
Number

[105]

Provider Info:

(PIA)

National
Provider ID
(NPI)

[109]

Provider Info:

(Required)

Medicare
Certification
Number
(Medicare ID)

[112]

Provider Info:

(Required)

State-specific
Provider ID
(Medicaid ID)

[107]

Provider Info:

(Required)

Provider Name

[108]

Provider Info:

(Required)

Ownership
Category
Type

[110]

Cost or Charge
Info:

(Required)

Begin Date for
Charge, Cost, or
Payment Data

[200.1]

Cost or Charge
Info:

(Required)

End Date for
Charge, Cost, or
Payment Data

[200.2]

Cost or Charge
Info:

(Required)

Per Diem
Charge, Cost, or
Payment

[223]

Cost or Charge
Info:

(Required)

Adjustments to
Per Diem Charge,
Cost, or Payment

[212.3]

Cost or Charge
Info:

(Calculated)

Total
Per Diem
Charge, Cost,
or Payment

[215]

MCD Info:

(Required)

Time Period of
Medicaid Days -
Begin Date

[300.1]

MCD Info:

(Required)

Time Period of
Medicaid Days -
End Date

[300.2]

MCD Info:

(Required)

Medicaid Days

[310]

MCD Info:

(Required)

Time Period of
Medicaid Rates -
Begin Date

[311.1]

MCD Info:

(Required)

Time Period of
Medicaid Rates -
End Date

[311.2]

MCD Info:

(Required)

Medicaid Base
Payment
Per Diem

[312]

MCD Info:

(Required)

Medicaid
Supplemental
Payment Per Diem

[313.1]

MCD Info:

(Required)

Medicaid
Supplemental
Payment Per Diem
(GME/Training)

[313.2]

MCD Info:

(Required)

Medicaid
Supplemental
Payment Per Diem
(Other)

[313.3]

MCD Info:

(Required)

Adjustment to
Medicaid
Per Diem #1

[314.1]

MCD Info:

(Required)

Adjustment to
Medicaid
Per Diem #2

[314.2]

MCD Info:

(Calculated)

Total Medicaid
Supplemental Payments
Per Diem with
Adjustments

[317]

MCD Inflated
Payment Info:

(PIA)

Medicaid
Inflation
Factor Type

[307]

MCD Inflated
Payment Info:

(Required)

Medicaid
Inflation
Factor

[308]

MCD Inflated
Payment Info:

(Required)

Other
Adjustment to
Medicaid
Payments

[309]

MCD Inflated
Payment Info:

(Calculated)

Inflated and
Adjusted
Medicaid
Payment Per Diem

[315]

MCD Inflated
Payment Info:

(Calculated)

Total
Medicaid
Payments

[316]

UPL Calc Info:

(PIA)

UPL Inflation
Factor Type

[404]

UPL Calc Info:

(Required)

UPL Inflation
Factor

[405]

UPL Calc Info:

(Calculated)

Inflated UPL
Per Diem

[400]

UPL Calc Info:

(Calculated)

Inflated
UPL Amount

[406]

UPL Adjustment
Info:

(Required)

Other
Adjustments to
the UPL Amount

[402]

UPL Adjustment
Info:

(Calculated)

Adjusted
Medicare
UPL Amount

[403]

UPL Gap
Info:

(Calculated)

UPL Gap
Amount

[407]

UPL Gap
Info:

(Required)

Adjustment
to the
UPL Gap

[408]

UPL Gap
Info:

(Calculated)

Adjusted
UPL Gap

[409]

No Data

End of Worksheet

Sheet 6: UPL Demonstration Summary

*Total Dollars by Ownership Type For: Total Base Payments ([312][310]), Total Supplemental Payments ([317][310), and Total Adjusted UPL Gap [409]*
Ownership Category	Total Base Payments	Total Supplemental Payments	Total Adjusted UPL Gaps
Private	$0	$0	$0
NSGO	$0	$0	$0
SGO	$0	$0	$0
Total	$0	$0	$0

Sheet 7: Optional_Sheet_1