HAR §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 UNOFFICIAL 1740.1-8 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 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. [Eff 11/20/03] (Auth: HRS §346-14, 42 C.F.R. §431.10) (Imp: Pub. L. No. 106-554) §17-1740.1-13 Cost reporting, record keeping, and audit requirements. (a) All participating facilities shall maintain an accounting system that identifies costs in a manner that conforms to generally accepted accounting principles and maintain documentation to support all data. (b) Annual cost reports will not generally be required, with the following exceptions: UNOFFICIAL 1740.1-9 (1) For participating FQHCs and RHCs that request changes to their scope of services under section 17-1740.1-11, cost reports for the first two full fiscal years reflecting the change in scope of services and significant related data as identified in paragraph (3) must be submitted. (2) For participating FQHCs and RHCs that request rate reconsiderations under section 17-1740.1-12, cost reports for the provider’s fiscal years covering the period for which the rate reconsideration was authorized and significant related data as identified in paragraph (3) must be submitted. (3) As related to provisions of paragraphs (1) and (2), the following shall be submitted no later than five months after the close of each facility’s applicable fiscal year and shall be subject to all provisions in this section.Uniform cost report; (A) Working trial balance; (B) Provider cost report questionnaire; (C) Audited financial statements, if available; (D) Disclosure of appeal items included in the cost report; (E) Disclosure of increases or decreases in scope of services; and (F) Other schedules as identified by the department. (c) Each provider who submits an annual cost report shall keep financial and statistical records of the cost reporting year for at least six years after submitting the cost report to the department and shall also make such records available upon request to authorized state or federal representatives. (d) The department or its fiscal agent may conduct periodically either on-site or desk audits of cost reports, including financial and statistical records of a sample of participating providers. (e) The providers must submit other information (statistics, cost and financial data) as deemed necessary by the department. [Eff 11/20/03] (Auth: HRS §346-14, 42 C.F.R. §431.10) (Imp: Pub. L. No. 106-554) UNOFFICIAL 1740.1-10