Effective for dates of service on or after July 1,
2014:
a) Rate Reviews
Hospitals shall be notified of their rates for the rate year
and shall have an opportunity to request a review, pursuant to subsection (f),
of any rate for errors in calculation made by the Department.
b) Disproportionate Share Hospital (DSH) and
Medicaid Percentage Adjustment (MPA) Determination Reviews
1) Hospitals shall be notified of their
qualification for DSH or MPApayment adjustments and shall have an opportunity
to request a review pursuant to subsection (f) of the DSH or MPA add-on for
errors in calculation made by the Department.
2) DSH or MPA determination reviews shall be
limited to the following:
A) DSH or MPA
Determination Criteria. The criteria for DSH determination shall be in
accordance with Section
148.120.
The criteria for MPA determination shall be in accordance with Section
148.122.
Review shall be limited to verification that the Department utilized criteria
in accordance with State regulations.
B) Medicaid Inpatient Utilization Rates.
i) Medicaid inpatient utilization rates shall
be calculated pursuant to Section 1923 of the Social Security Act and as
defined in Section
148.120(i)(4).
Review shall be limited to verification that Medicaid inpatient utilization
rates were calculated in accordance with federal and State
regulations.
ii) Hospitals'
Medicaid inpatient utilization rates, as defined in Section
148.120(i)(4),
which have been derived from unaudited cost reports, are not subject to the
Review Procedure with the exception of errors in calculation by the Department.
Pursuant to Section
148.120(c)(1)(B),
hospitals shall have the opportunity to submit corrected information prior to
the Department's final DSH or MPA determination.
C) Low Income Utilization Rates. Low Income
utilization rates shall be calculated in accordance with Section 1923 of the
Social Security Act, as defined in Section
148.120(a)(2).
Review shall be limited to verification that low income utilization rates were
calculated in accordance with federal and State regulations.
D) Federally Designated Health Manpower
Shortage Areas (HMSAs). Illinois hospitals located in federally designated
HMSAs shall be identified in accordance with 42 CFR 5(1989) and Section
148.122(a)(3)
based upon the methodologies utilized by, and the most current information
available to, the Department from the federal Department of Health and Human
Services. Review shall be limited to hospitals in locations that have failed to
obtain designation as federally designated HMSAs only when such a request for
review is accompanied by documentation from the Department of Health and Human
Services substantiating that the hospital was located in a federally designated
HMSA.
E) Excess Beds. Excess bed
information shall be determined in accordance with Public Act 86-268 (Section
148.122(a)(3)
and 77 Ill. Adm. Code
1100) based upon the
methodologies utilized by, and the most current information available to, the
Illinois Health Facilities Planning Board as of July 1, 1991. Reviews shall be
limited to requests accompanied by documentation from the Illinois Health
Facilities Planning Board substantiating that the information supplied to and
utilized by the Department was incorrect.
F) Medicaid Obstetrical Inpatient Utilization
Rates. Medicaid obstetrical inpatient utilization rates shall be calculated in
accordance with Section
148.122(g)(3).
Review shall be limited to verification that Medicaid obstetrical inpatient
utilization rates were calculated in accordance with State
regulations.
c) Outlier Adjustment Reviews
The Department shall make outlier adjustments to payment
amounts in accordance with 89 Ill. Adm. Code
149.105.
Hospitals shall be notified of the specific information that shall be utilized
in the determination of those services qualified for an outlier adjustment and
shall have an opportunity to request a review, pursuant to subsection (f), of
specific information for errors in calculation made by the Department.
d) Cost Report Reviews
Cost report reviews are described in Section
148.210(e).
e) Medicaid High Volume Adjustment
Reviews
The Department shall make Medicaid high volume adjustments in
accordance with Section
148.112.
Hospitals shall be notified of the Department's determination and have an
opportunity to request a review, pursuant to subsection (f). That review shall
be limited to verification that the Medicaid inpatient days were calculated in
accordance with Section 148.120.
f) Rate Review Requirements
1) Requests for Review
A) All requests for review must be submitted
in writing and must either be received by the Department, or post marked within
30 days after the date of the Department's notice to the hospital. The request
shall include:
i) a clear explanation of any
suspected error;
ii) any additional
documentation to be considered; and
iii) the desired corrective action.
B) The Department shall notify the
hospital of the results of the review within 30 days after receipt of the
hospital's request for review.
2) The review procedures provided for in this
Section may not be used to submit any new or corrected information that was
required to be submitted by a specific date in order to qualify for a payment
or payment adjustment. In addition, only information that was submitted
expressly for the purpose of qualifying for the payment or payment adjustment
under review shall be considered by the Department. Information that has been
submitted to the Department for other purposes will not be considered during
the review process.
3) For purposes
of this subsection (f), the term "post marked" means the date of processing by
the United States Post Office or any independent carrier service.
