Appeals of Rate Determinations

Section 140 TITLE 89: SOCIAL SERVICES CHAPTER I: DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES SUBCHAPTER d: MEDICAL PROGRAMS PART 140 MEDICAL PAYMENT SECTION 140.830 APPEALS OF RATE DETERMINATIONS Section 140.830  Appeals of Rate Determinations a)         Except as indicated in subsection (b), the Department shall notify all nursing facilities of their support and capital rates annually. Appeals of rate determinations shall be submitted in writing to the Department. Except as indicated in subsection (b), appeals received within 30 days after rate notification shall, if upheld, be made effective as of the beginning of the rate year. The effective date of all other upheld appeals shall be the first day of the month after the date the complete appeal was received. b)         The Department shall notify all nursing facilities of their nursing rate quarterly. Appeals shall be submitted to the Department no later than 30 days after the date of the Department's notice to the facility of the rate.  The results of an appeal shall become effective the first day of the applicable quarter. c)         Appeals of rate determinations under this Section shall be submitted in writing to the Chief, Bureau of Long Term Care.  The Department shall rule on all appeals within 120 days after the date of appeal, except that if the Department requires additional information from the facility the period shall be extended until such time as the information is provided.  Except for the rate identified in subsection (b), appeals for any rate year must be filed before the close of the rate year. d)         Appeals regarding missing Payroll Based Journal (PBJ) data. 1)         Certified Nursing Assistant (CNA) Incentive Payments A)        Facilities participating in the CNA Incentive Program that fail to timely submit Payroll Based Journal (PBJ) data will not be paid the CNA incentive payments for the applicable quarter. B)        Facilities participating in the CNA Incentive Program who timely submit PBJ data that is ultimately suppressed by the federal Centers for Medicare and Medicaid Services (CMS), will be paid at 90% of their most recent quarter's CNA incentive payment. An additional 10% reduction will be applied to the resulting payment for each sequentially suppressed quarter. (90%, 80%, 70%, etc.) All other quarterly program requirements must still be met to receive the reduced payments on appeal. 2)         Nurse Staffing Add-On Payments A)        Facilities that fail to timely submit PBJ data utilized in the nurse staffing add-on calculation located at 89 Ill. Adm. Code 147.310(c)(3) will receive a staffing percentage of 0% for the quarter. B)        Facilities who timely submit nurse staffing PBJ data that is ultimately suppressed on the Provider Information File by federal CMS, will be required to submit information on the reason for suppression (facility error or federal audit). Facilities will receive a staffing percentage equal to their most recent quarter's staffing percentage less 10 percentage points, unless the reason for suppression indicates that the percentage of reported hours was overstated by more than 10%, in which case a higher penalty equal to the overstated percentage is justified. An additional reduction of 10 percentage points will be applied to the resulting staffing percentage for each sequentially suppressed quarter.