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Instructions for completing the Pro-Forma for Provider Self-Determination of Aggregate Cap Limitation

Ordering Required Reports from EIDM

In order to fill out the information needed on the Pro-Forma, the provider will need to order the following reports from Enterprise Identify Management System (EIDM), formerly IACS.

  1. The PS&R summary report for the cap period.  The cap period is always 10/01 through 09/30 for the cap year. Please make sure you change service period to up dates and do not use your default Fiscal year end service period.
    • Please change service period to match the dates cap period you are submitting for and do not use the default Fiscal service period(s) that match your agency’s Fiscal Year End.

      Cap year

      Payments

      Streamlined method

      Patient-by-patient proportional method

      2016

      11/1/15-10/31/16

      11/1/15-10/31/16

      2017 (Transition Year)

      11/1/16-9/30/17

      11/1/16-9/30/17

      2018 and later

      10/1-9/30

      10/1-9/30

    • Do not use the unduplicated Census count from this report as your Benecficiary count. (See #2 below to obtained your Beneficiary count)
    • Change from paid date to 08/01/2007
  2. Hospice Beneficiary Count Summary – Instructions for ordering the correct period are:
    • Choose “Request Report”.
    • Choose “Request Miscellaneous”.
    • From drop down box, choose “Hospice Cap Report”.
    • Enter Beneficiary Identification Period (Format: MM/DD/YYYY).

      Cap year

      Beneficiaries

      Streamlined method

      Patient-by-patient proportional method

      2016

      9/28/15-9/27/16

      11/1/15-10/31/16

      2017 (Transition Year)

      9/28/16-9/30/17

      11/1/16-9/30/17

      2018 and later

      10/1-9/30

      10/1-9/30

    • Paid date: leave at default.  Through date: should be left at current; however, must be on or after 12/31/2017 to make a valid 2017 reporting.
    • The Report Type selected should match the method reported on line 1a of the Pro-forma and should match the prior year cap methodology.  Note for new providers --  The only option is the patient-by-patient proportional method.
    • Select Report Format.
    • Select continue and submit to order the report.
    • The Hospice Beneficiary Count Summary report will be delivered to the Miscellaneous Report Inbox after processing (usually overnight).

Completing the Pro-Forma

Provider input is required in all the gray shaded boxes of the form.

Provider Name, Number, NPI, and Cap Year are to be reported in header section.  The Cap Year ending date is always 09/30 of the year being reported (i.e., for the 2017 cap period, this is 09/30/2017).

Line 1: Medicare Beneficiaries under hospice care per the PS&R:  This amount is obtained from Hospice Beneficiary Count Summary report generated in EIDM.  The total beneficiary count for the Cap Year being reported is input on line 1.

Line 1a:  There are two different methods for counting a hospice’s beneficiaries -- the streamlined method or the patient-by-patient proportional method.  The method used needs to match the method used for the prior cap period.  New providers are required to use the patient-by-patient proportional method.

Line 1b:  This is the paid through date on the Hospice Beneficiary Count Summary report.  The date must be 12/31 or later.

Line 2:  Statutory Cap Amount for the Cap Year.  This amount is published in the Federal Register every year and is available on the CMS or MAC website.  For 2017, this amount is $28,404.99.

Line 3:  Allowable Medicare Payments.  Multiply line 1 (Medicare Beneficiaries under Hospice Care per the PS&R) times line 2 (Statutory Cap Amount for the Cap Year).

Line 4:  The net reimbursement from the summary PS&R for the cap period is included on this line.  Note that, if sequestration applies for this cap period, the contractor will make the adjustment at the final cap determination. 

Line 5: Payments in Excess of the Aggregate Cap Amount.  Subtract line 4 from line 3.  If the result is a positive amount, zero should be entered on this line.  If the result is a negative amount, an overpayment has been calculated and is due to the Medicare Program.  This amount is due at the time of submission of the Self-Determined Aggregate Cap Limitation. 

Certification:  The Pro-Forma is signed by an authorized person at the hospice.  The printed name and title of the signer, as well as the name and telephone number of a contact, are to be included on the form.

 


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