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Documentation Deadline Set for Hospital Appeals of Medicaid Eligible Days

The Centers for Medicare & Medicaid Services’ (CMS’) Office of Hearings issued an alert May 23 notifying providers with pending appeals on Medicaid paid and unpaid eligible days that they have until July 22 to submit certain information to the Provider Reimbursement Review  Board (PRRB). Providers with pending appeals on the number of Medicaid eligible days used in the calculation of the Medicaid fraction of their disproportionate patient percentage (DPP) must provide three types of supporting information and documentation to the PRRB:

  • a thorough explanation of how the provider identified and counted the actual Medicaid paid and unpaid eligible days on its Medicare cost report for the fiscal year in question
  • the number of additional Medicaid paid and unpaid eligible days the provider requests to be used in the calculation of the DPP
  • a detailed account of why the additional Medicaid eligible days were not verified and included in the cost report that was filed

CMS issued this alert in response to a PRRB decision to decline jurisdiction over the Medicaid eligible days issue, noting that the provider in this case had not sufficiently explained why it did not include the Medicaid eligible days in its cost report. To appeal a reimbursement determination for a particular item, a provider either has to have claimed that item on its cost report or provided a reason for not including it on the cost report. Thus, according to the current alert, the PRRB will only accept supplemental documentation from providers with pending appeals that will help determine whether the providers have offered sufficient explanation to give the PRRB jurisdiction over these appeals. Providers with pending appeals on this issue are urged to provide this information to the PRRB by the deadline.

Please contact Xiaoyi Huang, JD, director of policy, at xhuang@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Shahid Zaman is a senior policy analyst at America's Essential Hospitals.