Instructions for Completion of the IBPR - (Rev. 5, 08-30-02)

90.6 - Instructions for Completion of the IBPR - (Rev. 5, 08-30-02) A1-1414.6 A. Heading The contractor enters its name and assigned number. Multi-regional intermediaries use the number assigned to the home office for administrative budget and cost reporting purposes. The contractor shall furnish a consolidated report for all locations. The contractor enters the calendar month and year as a four-digit entry, e.g., 1000, 1100, 1200, 0101. B. Column Definitions - Page 1 Column (a) - Single Facility - refers to payments to PPS hospitals that do not have distinct part facilities, such as SNFs, HHAs, psychiatric units, or rehabilitation units. • Column (b) - Facility With Distinct Parts - refers to payments to PPS hospitals that include distinct parts, such as SNFs, HHAs, psychiatric units, or rehabilitation units. NOTE: The contractor enters non-PPS payments to the distinct part on the appropriate line and column of page 2. • Column (c) - Non-PPS Payment - refers to payments to the following: o Hospitals excluded from PPS (e.g., psychiatric, children's, rehabilitation and long term); o Hospitals receiving payments via an alternative payment program (waiver States); o Hospitals yet to be phased into PPS; and o PPS hospitals for bills or underpayments applicable to pre-PPS fiscal years. • Column (d) - Total - refers to the total of columns (a), (b), and (c). C. Line Item Definitions - Page 1: 1. Hospital Inpatient (PIP) - refers to hospitals paid by the PIP method. The contractor shall show these figures less any deductibles, coinsurance, and interest for all items on the PIP bills and any sequestration applicable to this line with any offsets shown on line 6A or 6B. A. Inpatient Operating Payments - refers to the amount of the PIP that covers items that would otherwise be paid on a per claim basis plus those items paid on a per claim basis in addition to PIP payment. (Such as payments for outliers and hemophilia blood clotting factor add-on.) The contractor enters the PIP amounts paid as follows: PPS Provider Payments - Payments related to services furnished after conversion to PPS in columns 1(a) or 1(b), as applicable. This includes outlier payments, hemophilia blood clotting factor add-on payments, disproportionate share amounts, indirect medical education, ESRD payments, and phased-in capital-related costs during the transition period. Non-PPS Provider Payments - column (c) - Payments related to services furnished prior to conversion to PPS. Payments to all providers listed in the definitions for column (c). B. Pass Through Costs - Contractor enters the PIP payments, including any withholdings, but less any sequestration amounts for items paid on a reasonable cost basis as follows: • Capital; • Direct medical education which includes nursing and paramedical health professional (allied health) programs and graduate medical education; • Kidney and other organ acquisitions; • Bad debts; and • Nonphysician anesthetists. NOTE: This includes that part of capital-related costs not included in line 1A. C. Indirect Medical Education - Contractor enters the PIP payments for the indirect medical education adjustment, whether on a PIP or a claim-by- claim basis for PIP providers, less any sequestration (already included in line 1A). NOTE: Contractor shall make entries on this line for memorandum purposes only to identify the amount of indirect medical education for PIP hospitals. 2. Hospital Inpatient (Non-PIP), refers to hospitals paid based upon bills reviewed and approved. Contractor shall show total payments less any reductions on line 6A or line 6B. A. DRG Bills Paid/Non-DRG Bills Paid - Contractor enters the calculated payment less any deductibles, coinsurance, and interest for all items on the bill and any sequestration applicable to this line. It shall include payments for outliers, disproportionate share, indirect medical education, high percentage of end-stage renal disease beneficiary discharges, and hemophilia blood clotting factor add-on payments on a claim-by-claim basis. Also, it shall include phased-in capital-related costs during the transition period. For DRG bills, it shall use columns (a) and (b). For non-DRG bills paid, it shall use column (c). It shall report all retroactive adjustments pertaining to hospitals on line 6A or 6B. B. Pass Through Costs - The contractor enters the interim payments, less any sequestration, for items paid on a reasonable cost basis as follows: • Capital; • Direct medical education which includes nursing and paramedical health professional (allied health) programs and graduate medical education; • Kidney and other organ acquisitions; • Bad debts; and • Nonphysician anesthetists. NOTE: This includes that part of the capital-related costs that are not included in line 2A. C. Indirect Medical Education - Contractor enters the interim payments for the indirect medical education adjustment (already included in line 2A). NOTE: Contractor shall make entries on this line for memorandum purposes only to identify the amount of indirect medical education for non-PIP hospitals. It shall not adjust these amounts for MSP or sequestration. 3. Outlier Payments - Contractor enters additional amounts paid for outlier cases. NOTE: Contractor shall make entries on this line for memorandum purposes only to identify the total outlier payments that are found in the UB82 billing form in Locator 46- 49 in Value Code 17. These amounts are already included in the amounts recorded on lines lA and 2A. A. Days - The contractor enters additional payments made as a result of the length of stay exceeding the day outlier threshold criteria. It shall make entries on this line for memorandum purposes only. These are non-add items. NOTE: After FY 1997, outlier days no longer exist. B. Cost - The contractor enters additional payments made for claims where extraordinary costs were approved. It shall make entries on this line for memorandum purposes only. These are non-add items. 4. Subtotal - Contractor enters the total of the amounts on lines 1A, 1B, 2A, and 2B. NOTE: The amounts included in lines 1C, 2C, 3A and 3B are memo entries only and have been included in lines 1A, 1B, 2A and 2B. 5. Outpatient Payments - Contractor enters the payment, less deductibles, coinsurance and sequestration for outpatient and Part B inpatient services. It shall report any offset against these amounts on line 6A or 6B. See line 19 for reporting SNF outpatient payments. 6. Retroactive Adjustments: • PPS Provider Payments - Contractor enters on lines 6A and 6B (as applicable), columns (a) or (b), the net amount of retroactive adjustments paid and received as a result of interim rate adjustments, pass through cost adjustments, and cost report settlements applicable to current or prior provider fiscal years. Contractor shall show interest on cost report overpayments and late-filed cost reports on these lines. An example of a proper recording of a retroactive adjustment would be an entry of $500,000 of cash received from the provider as the first installment of the final settlement of $1,000,000 due the program from the prior year's cost report. Another example would be an entry of $500,000 offset against current PIP payments due of $1,000,000. (The $1,000,000 would be shown on line 1A.) • Non-PPS Provider Payments - Contractor enters on line 6A or 6B (as applicable) in column (c) the net amount of retroactive adjustments paid and received as a result of interim rate adjustments and cost report settlements applicable to current or prior provider fiscal years. It shall show interest on cost report overpayments and late-filed cost reports on these lines. 7. Accelerated Payments - Contractor enters the net amount of accelerated payments made to and collected from hospitals and distinct part units. (See §160.5 for an explanation of the appropriate recording of offsets.) 8. Total - The contractor enters the total of lines 4 through 7. D. Statistical Data-Hospitals-Page 1: 9. PIP: A. Contractor enters the total number of bills processed for hospitals paid by the PIP method. B. Contractor enters the dollar amount that would have been paid if the bills processed were not subject to PIP in accordance with the definition of line 2A. 10. Non-PIP - Contractor enters the total number of bills for hospitals paid on a submitted-bill basis. 11. Number of Hospitals - Contractor enters the total number of hospitals participating in the Medicare program. 12. Number of Admissions - Contractor enters the total number of admissions the Common Working File (CWF) has approved for payment. 13. Number of Discharges - Contractor enters the number of discharge bills processed during the reporting month. 14. Number of Readmissions - Contractor enters the total number of readmissions to a hospital within 7 calendar days of discharge from an acute care facility. 15. Number of Transfers - Contractor enters in column (a) and column (b) the total number of transfers to a PPS hospital. It enters in column (c) the total number of transfers to a non-PPS hospital. 16. Outlier Bills: A. Days - Contractor enters the total number of day outlier bills paid that relate to the dollar amounts shown in line 3A. NOTE: Outlier days have been obsolete since the end of FY 1997. B. Costs - Contractor enters the total number of cost outlier bills paid that relate to the dollar amounts shown in line 3B. 17. Outpatient - Contractor enters the total number of outpatient bills and Part B inpatient bills paid that relate to the dollar amounts shown in line 5. E. Column Definitions - Page 2 • Column (e) - Single Facility - Refers to all providers that are not part of a hospital complex. • Column (f) - Part of Hospital Complex - Refers to providers that are an integral part of a hospital and are operated with other departments of the hospital under common licensure and governance. • Column (g) - Total - Refers to total of columns (e) and (f). F. Line Item Definitions - Page 2 Skilled Nursing Facilities - Including swing bed payments for SNF care. 18. PIP - Contractor enters all PIP payments made to SNFs. It enters total payments (less any deductibles, coinsurance, interest or sequestration) with any withholding reductions being shown on line 20. 19. Bills Paid - Contractor enters total payments less any deductibles, coinsurance, interest, or sequestration with any withholdings shown on line 20. It enters the calculated payment, less any deductibles, coinsurance and interest for all items, and any sequestration applicable to SNFs on a submitted-bill basis. It shall include Part A and Part B services. 20. Retroactive Adjustments - Contractor enters the net amount of retroactive adjustments paid and received as a result of cost report settlements and lump sum interim rate adjustments made in prior or current provider fiscal years. 21. It shall show interest on cost report overpayments and late-filed cost reports on this line. An example of a proper recording of a retroactive adjustment would be an entry of $500,000 cash received from the provider as the first installment of the final settlement of $1,000,000 due the program from the prior year's cost report. 22. Accelerated Payments - Contractor enters the net amount of accelerated payments made to and collected from SNFs. (See §160.5) for an explanation for reporting accelerated payments.) 23. Total SNF Payments - Contractor enters the total of lines 18 through 21. Home Health Agencies: 23. PIP - Contractor enters all PIP payments made to HHAs including SNF-based. 24. It shall show total payments less any deductibles, coinsurance, interest, or sequestration with any withholding reductions shown on line 25. 25. Bills Paid - Contractor shall show total payments (less any deductibles, coinsurance, interest, or sequestration) with any withholdings shown on line 25. It enters the calculated payment, less any deductibles, coinsurance, and interest, for all items, and any sequestration applicable to HHAs on a submitted-bill basis. It shall include Part A and Part B services and SNF-based HHAs payments. 26. Retroactive Adjustments - Contractor enters the net amount of retroactive adjustments paid and received as a result of cost report settlements and lump sum interim rate adjustments made in prior current provider fiscal years. 27. It shall show interest on cost report overpayments and late-filed cost reports on this line. An example of a proper recording of a retroactive adjustment would be an entry of $500,000 cash received from the provider as the first installment of the final settlement of $1,000,000 due the program from the prior year's cost report. 28. Accelerated Payments - Contractor enters the net amount of accelerated payments made to and collected from HHAs. (See §160.5) for an explanation for reporting accelerated payments.) 29. Total HHA Payments - Contractor enters the total of lines 23 through 26. Additional Providers: 28. ESRD - Contractor shall include in these columns payments to ESRD networks, as applicable: Column (e) - It enters net payments to independent facilities. Column (f) - It enters net payments to hospital-based facilities. 29. Hospice - Contractor enters net payments made to hospices. 30. RHC - Contractor enters net payments made to rural health clinics (RHCs). 31. OPA/HL - Contractor enters net payments made to organ procurement agencies and histocompatibility laboratories. 32. CORF - Contractor enters net payments made to comprehensive outpatient rehabilitation facilities (CORFs). 33. Distinct Part Units - Contractor enters net payments made to exempt distinct part rehabilitation and psychiatric units. 34. All Others - Contractor enters net payments made to other providers not listed in lines 28 -33. NOTE: Contractor shall make adjustments, pertaining to providers, identified on lines 28 through 34 directly to the specific line. This includes checks received and offsets or withholdings. 35. Total - Contractor enters the total of lines 28 through 34. 36. Grand Total - Contractor enters the total of lines 8(d), 22(g), 27(g) and 35(g). G. Statistical Data - Page 2: 37. SNF: • Number of SNFs - Contractor enters the total number of participating SNFs. • Number of Admissions - Contractor enters the total number of SNF admissions. 38. HHA: • Number of HHAs - Contractor enters the total number of participating HHAs. • Number of Bills - Contractor enters the total number of bills processed. (Audit intermediaries should not complete this line.) 39. Number of Transfers to Distinct Part Units - Contractor enters the total number of transfers to distinct part units for which payments are shown in line 33. It shall use edit checks to ensure completeness, arithmetical accuracy, and to discover inconsistencies. It shall have an authorized official sign and date the report.