471 NAC 46-027. REQUEST FOR RATE ADJUSTMENTS

027. REQUEST FOR RATE ADJUSTMENTS. Requests for rate adjustments are subject to the rules contained in this section. 027.01 REQUESTS. Hospitals may submit a request to Nebraska Medicaid for an adjustment to their rates for the following: (A) If the rate-setting methodology or principles of reimbursement established under the State Plan were incorrectly applied, or if incorrect data or erroneous calculations were used in the establishment of the hospital's rate; (B) For extraordinary circumstances that are not faced by other Nebraska hospitals in the provision of hospital services. Extraordinary circumstances are limited to circumstances occurring since the base year that are not addressed by the reimbursement methodology. Extraordinary circumstances are limited to: (i) Changes in routine and ancillary costs, which are limited to: (1) Intern and resident related medical education costs; and (2) Establishment of a subspecialty care unit; and (ii) Extraordinary capital-related costs. Adjustment for capital-related costs will be limited to no more than a five percent increase; or (C) If they incur allowable costs as a consequence of a natural or other catastrophe. The following circumstances must be met to be considered a catastrophic circumstance: (i) One-time occurrence; (ii) Less than twelve-month duration; (iii) Could not have been reasonably predicted; (iv) Not of an insurable nature; (v) Not covered by federal or state disaster relief; and (vi) Not a result of malpractice or negligence. 027.02 REQUIREMENTS. A request for adjustment for circumstances other than a correction of an error, the requesting hospital shall demonstrate the following: changes in costs are the result of factors generally not shared by other hospitals in Nebraska, such as improvements imposed by licensing or accrediting standards, the rate the hospital receives is insufficient to provide care and service that conforms to applicable state and federal laws, regulations, and quality and safety standards, or extraordinary circumstances beyond the hospital's control; and every reasonable action has been taken by the hospital to mitigate or contain resulting cost increases. Nebraska Medicaid may request that the hospital provide additional quantitative and qualitative data to assist in evaluation of the request. Nebraska Medicaid may require an on-site operational review of the hospital be conducted by Nebraska Medicaid or its designee. In all circumstances, requests for adjustments to rates must be calculable and auditable. Requests must specify the nature of the adjustment sought and the amount of the adjustment sought. The burden of proof is that of the requesting hospital. 027.03 SUBMISSION. Requests for rate adjustments must be submitted in writing to Nebraska Medicaid . Requests must be received within 45 days after one of the above circumstances occurs or the notification of the facility of its prospective rates. Upon receipt of the request, Nebraska Medicaid shall determine the need for a conference with the hospital and will contact the facility to arrange a conference if needed. The conference, if needed, must be held within 60 days of Nebraska Medicaid's receipt of the request. Regardless of Nebraska Medicaid's decision, the provider will be afforded the opportunity for a conference if requested for a full explanation of the factors involved and Nebraska Medicaid's decision. Following review of the matter, Nebraska Medicaid shall notify the facility of the action to be taken within 30 days of receipt of the request for review or the date of the conference, except in circumstances where additional information is requested or additional investigation or analysis is determined to be necessary by Nebraska Medicaid. If rate relief is granted because of a rate adjustment request, the relief applies only to the rate year for which the request is submitted, except for corrections of errors in rate determination. If the provider believes that continued rate relief is justified, a request in any subsequent year may be submitted. Under no circumstances shall changes in rates resulting from the request process result in payments to a hospital that exceed its actual Nebraska Medicaid cost, calculated in conformity with this Nebraska Medicaid cost calculation methodology. Nebraska Medicaid’s decision regarding rate adjustment requests is final and non-appealable.