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Frequently Asked Questions

Frequently Asked Questions are used to provide additional information and/or statutory guidance not found in State Medicaid Director Letters, State Health Official Letters, or CMCS Informational Bulletins. The different sets of FAQs as originally released can be accessed below.

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What are examples of what would be appropriate adjustments to the Upper Payment Limit (UPL) in step 9 (Adjustments to the UPL and UPL Gap Calculation) (field 408) of the template?

Variable 408 (Adjustment to the UPL Gap) is intended to allow states to report adjustments to their UPL gap, to the extent that these adjustments are not accounted for in other variables. Here, states could report broad-based increases or reductions in payment, such as a Medicaid volume adjustment for managed care expansion. The source of values input into variable 408 may differ by state. Whenever a state reports data in variable 408 it must include a comprehensive note describing the adjustment.

FAQ ID:92301

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Can CMS provide a list of the revenue codes that are approved to be included in the outpatient hospital Upper Payment Limit (UPL) or conversely the revenue codes that cannot be included?

To date, CMS has not published a list of revenue codes that must be included or excluded from this service category.  Medicaid outpatient hospital services are defined at 42 Code of Federal Regulations (CFR) 440.20 and include “preventive, diagnostic, therapeutic, rehabilitative, or palliative services”.  In the state plan, states further define those services covered as outpatient hospital services.

FAQ ID:92411

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How should a state report Upper Payment Limit (UPL) data for out of state providers?

The UPL data for out of state providers does not need to be included in the UPL demonstration. If the state has provider level data then it may include it in the demonstration within the private ownership category of providers.

FAQ ID:92426

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