Haw. Code R. § 17-1740.1-12 - Rate reconsideration
(a) Providers shall
have the right to request a rate reconsideration if extraordinary circumstances
beyond the control of the provider occur after December 31, 2001 and PPS
payments are insufficient due to these extraordinary circumstances.
Extraordinary circumstances include, but are not limited to acts of God,
changes in life and safety code requirements, and changes in licensure law, and
rules or regulations. Mere inflation of cost, absent extraordinary
circumstances, shall not be grounds for rate reconsideration. If a provider's
PPS rate is sufficient to cover its overall costs including those associated
with the extraordinary circumstances, then a rate reconsideration is not
warranted.
(b) The department will
accept a request for rate reconsideration for a prospective payment year at any
time during that prospective payment year or within thirty days following the
end of that prospective payment year.
(c) Requests for rate reconsiderations shall
be submitted in writing to the department and shall set forth the reasons for
the requests. Each request shall be accompanied by sufficient documentation to
enable the department to act upon the request. Documentation shall include the
data necessary to demonstrate that the circumstances for which reconsideration
is requested meet the requirements noted above. Documentation shall include the
following:
(1) A presentation of data to
demonstrate reasons for the provider's request for a rate
reconsideration.
(2) The rate
reconsideration request must be accompanied by documentation showing the cost
implications. The cost impact must be material and significant ($200,000 or one
per cent of a facility's total costs, whichever is less). Documentation must be
sufficient to compute an adjustment amount to the PPS rate for the purpose of
determining a managed care supplemental payment amount if necessary.
(d) Each rate reconsideration
request will be applicable only for the remainder of the PPS rate year. If the
reconsideration request is granted, it will be effective no earlier than the
first date of the PPS rate year during which the reconsideration request is
received. If a provider believes that its experience justifies continuation of
the reconsidered rate in subsequent years, then it shall submit information to
update the documentation provided in the prior request. A request must be
submitted for each affected year.
(e) Amounts granted for rate reconsideration
requests will be paid as lump-sum amounts for those years and not as revised
PPS rates.
(f) The provider shall
be notified of the department's decision in writing within ninety calendar days
from the date all necessary verification and documentation have been
provided.
(g) A provider may appeal
the department's (Formatted: Bullets and Numbering) decision on
the rate reconsideration if the Medicaid impact is $10,000 or more. The appeal
shall be filed in accordance with the procedural requirements of chapter
17-1736.
Notes
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