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MU: State Assumptions

Version 14.19

Each state is listed as a link in the Group tables for reference to determine a given state’s methodology.  Occasionally states have published vague or contradictory information about the methodology listed, which we have made efforts to clarify.  While the states are categorized based on OP’s best understanding of each state’s description of its current methodology, it is each practice’s responsibility to confirm with your state’s Medicaid agency that the assumptions made below are current for the reporting year as of the date of the practice’s attestation.

Group 1 States Assumptions

  • The volume attestation is for periods AFTER 1/1/2013 (volume attestations were computed using a different methodology prior to 1/1/2013). If you are attesting to volume for a period prior to 1/1/2013, this report may not be able to be used.
  • The “encounter” volume methodology is acceptable (as opposed to the “panel” volume methodology, which is not used here).  
  • The reporting practice/providers are not part of a rural health clinic (RHC), federally-qualified health center (FQHC), or another entity that is permitted to use “needy patient volume” rather than strictly Medicaid encounters.
  • “Zero pay claims” are acceptable to include as long as the patient had Medicaid on the date of service.
  • The practice may include any patient with Medicaid seen during the period, even if it was not the primary insurance on the date of service.
  • The report may use the rendering provider only, rather than double attribution using both rendering and billing provider.
  • The providers only have clinical practices in one state.
  • No out of state Medicaid plans appear in the practice’s “Medicaid Plans SQL” report.
  • This provider (for individuals) or all of the providers (for groups) perform(s) no more than 90% of their services in a hospital (place of service 21 or 23).
  • The practice can easily segregate Medicaid eligibles from CHIP eligibles into different OP insurance plans. The CHIP plans do not appear in the practice’s “Medicaid Plans SQL” report. As such, the practice does not need to make any “CHIP factor adjustments’ to the report.

Group 2 States Assumptions

  • The volume attestation is for periods AFTER 1/1/2013 (volume attestations were computed using a different methodology prior to 1/1/2013).  If you are attesting to volume for a period prior to 1/1/2013, this report may not be able to be used.
  • The “encounter” volume methodology is acceptable (as opposed to the “panel” volume methodology, which is not used here).  
  • The reporting practice/providers are not part of a rural health clinic (RHC), federally-qualified health center (FQHC), or another entity that is permitted to use “needy patient volume” rather than strictly Medicaid encounters.
  • “Zero pay claims” are acceptable to include, as long as the patient had Medicaid on the date of service.
  • The practice may include any patient with Medicaid seen during the period, even if it was not the primary insurance on the date of service.
  • The report may use the rendering provider only, rather than double attribution using both rendering and billing provider.
  • The providers only have clinical practices in one state.
  • No out of state Medicaid plans appear in the practice’s “Medicaid Plans SQL” report.
  • This provider (for individuals) all of the providers (for groups) performs no more than 90% of their services in a hospital (place of service 21 or 23).
  • The state assumes the practice CANNOT easily segregate Medicaid eligibles from CHIP eligibles into different OP insurance plans.  That is, a child eligible through Medicaid and a child eligible through CHIP appear to be covered by identical plans.  Because these two types of eligibles cannot be reasonably differentiated, some CHIP eligibles will appear in the practice’s “Medicaid Plans SQL” report and the practice needs to make a “CHIP factor adjustment” as part of its attestation process.
  • “CHIP factor adjustments” are made by adjusting your reported Medicaid visits downward by a fixed percentage. This is applied to the numbers you get through the SQL.   
    • When you run your attestation SQL, you will be asked to enter your adjustment factor:
      • The factor is usually given as a percentage (e.g. 3.2%). Enter it as a decimal (0.032).
      • Sometimes the factor 3.2% is expressed as its inverse (96.8%). Be sure you are entering a single-digit percent (e.g. 0.032, not 0.968). 
  • You may be asked to report the pre-adjustment number, post-adjustment number, or both (depending on your state’s attestation process).

Group 3 States Assumptions

  • The volume attestation is for periods AFTER 1/1/2013 (volume attestations were computed using a different methodology prior to 1/1/2013).  If you are attesting to volume for a period prior to 1/1/2013, this report may not be able to be used.
  • The “encounter” volume methodology is acceptable (as opposed to the “panel” volume methodology, which is not used here).  
  • The reporting practice/providers are not part of a rural health clinic (RHC), federally-qualified health center (FQHC), or another entity that is permitted to use “needy patient volume” rather than strictly Medicaid encounters.
  • “Zero pay claims” are acceptable to include, as long as the patient had Medicaid on the date of service.
  • The practice may include any patient with Medicaid seen during the period, even if it was not the primary insurance on the date of service.
  • The report may use the rendering provider only, rather than double attribution using both rendering and billing provider.
  • The providers only have clinical practices in one state.
  • No out of state Medicaid plans appear in the practice’s “Medicaid Plans SQL” report.
  • This provider (for individuals) all of the providers (for groups) performs no more than 90% of their services in a hospital (place of service 21 or 23).
  • The practice is in a state in which Medicaid expansion funds are used to fund its CHIP program and thus all CHIP eligibles may be included in the encounter volume calculation.  Thus, the practice may include CHIP plan insurance codes in its “Medicaid Plans SQL” report but need not make any “CHIP factor adjustments”.

Group 4 States Assumptions

  • The volume attestation is for periods AFTER 1/1/2013 (volume attestations were computed using a different methodology prior to 1/1/2013). If you are attesting to volume for a period prior to 1/1/2013, this report may not be able to be used.
  • The “encounter” volume methodology is acceptable (as opposed to the “panel” volume methodology, which is not used here).  
  • The reporting practice/providers are not part of a rural health clinic (RHC), federally-qualified health center (FQHC), or another entity that is permitted to use “needy patient volume” rather than strictly Medicaid encounters.
  • “Zero pay claims” are acceptable to include, as long as the patient had Medicaid on the date of service. However, zero pay claims must be individually counted and reported.
  • The practice may include any patient with Medicaid seen during the period, even if it was not the primary insurance on the date of service.
  • The report may use the rendering provider only, rather than double attribution using both rendering and billing provider.
  • The providers only have clinical practices in one state.
  • No out of state Medicaid plans appear in the practice’s “Medicaid Plans SQL” report.
  • This provider (for individuals) all of the providers (for groups) performs no more than 90% of their services in a hospital (place of service 21 or 23).
  • The practice can easily segregate Medicaid eligibles from CHIP eligibles into different OP insurance plans, and CHIP plans do not appear in the practice’s “Medicaid Plans SQL” report. As such, the practice does not need to make any “CHIP factor adjustments’ to the report.

Group 5 States Assumptions

We couldn’t figure out where these states are grouped.  If you need to attest in one for one of the states listed below, please contact your state Medicaid office to find out its rules and share them with OP. Sharing your findings can help us help you find the right attestation report(s).

  • Montana
  • Virginia
Version 14.10

Each state is listed as a link in the Group tables for reference to determine a given state’s methodology.  Occasionally states have published vague or contradictory information about the methodology listed, which we have made efforts to clarify.  While the states are categorized based on OP’s best understanding of each state’s description of its current methodology, it is each practice’s responsibility to confirm with your state’s Medicaid agency that the assumptions made below are current for the reporting year as of the date of the practice’s attestation.

Group 1 States Assumptions

  • The volume attestation is for periods AFTER 1/1/2013 (volume attestations were computed using a different methodology prior to 1/1/2013). If you are attesting to volume for a period prior to 1/1/2013, this report may not be able to be used.
  • The “encounter” volume methodology is acceptable (as opposed to the “panel” volume methodology, which is not used here).  
  • The reporting practice/providers are not part of a rural health clinic (RHC), federally-qualified health center (FQHC), or another entity that is permitted to use “needy patient volume” rather than strictly Medicaid encounters.
  • “Zero pay claims” are acceptable to include as long as the patient had Medicaid on the date of service.
  • The practice may include any patient with Medicaid seen during the period, even if it was not the primary insurance on the date of service.
  • The report may use the rendering provider only, rather than double attribution using both rendering and billing provider.
  • The providers only have clinical practices in one state.
  • No out of state Medicaid plans appear in the practice’s “Medicaid Plans SQL” report.
  • This provider (for individuals) or all of the providers (for groups) perform(s) no more than 90% of their services in a hospital (place of service 21 or 23).
  • The practice can easily segregate Medicaid eligibles from CHIP eligibles into different OP insurance plans. The CHIP plans do not appear in the practice’s “Medicaid Plans SQL” report. As such, the practice does not need to make any “CHIP factor adjustments’ to the report.

Group 2 States Assumptions

  • The volume attestation is for periods AFTER 1/1/2013 (volume attestations were computed using a different methodology prior to 1/1/2013).  If you are attesting to volume for a period prior to 1/1/2013, this report may not be able to be used.
  • The “encounter” volume methodology is acceptable (as opposed to the “panel” volume methodology, which is not used here).  
  • The reporting practice/providers are not part of a rural health clinic (RHC), federally-qualified health center (FQHC), or another entity that is permitted to use “needy patient volume” rather than strictly Medicaid encounters.
  • “Zero pay claims” are acceptable to include, as long as the patient had Medicaid on the date of service.
  • The practice may include any patient with Medicaid seen during the period, even if it was not the primary insurance on the date of service.
  • The report may use the rendering provider only, rather than double attribution using both rendering and billing provider.
  • The providers only have clinical practices in one state.
  • No out of state Medicaid plans appear in the practice’s “Medicaid Plans SQL” report.
  • This provider (for individuals) all of the providers (for groups) performs no more than 90% of their services in a hospital (place of service 21 or 23).
  • The state assumes the practice CANNOT easily segregate Medicaid eligibles from CHIP eligibles into different OP insurance plans.  That is, a child eligible through Medicaid and a child eligible through CHIP appear to be covered by identical plans.  Because these two types of eligibles cannot be reasonably differentiated, some CHIP eligibles will appear in the practice’s “Medicaid Plans SQL” report and the practice needs to make a “CHIP factor adjustment” as part of its attestation process.
  • “CHIP factor adjustments” are made by adjusting your reported Medicaid visits downward by a fixed percentage. This is applied to the numbers you get through the SQL.   
    • When you run your attestation SQL, you will be asked to enter your adjustment factor:
      • The factor is usually given as a percentage (e.g. 3.2%). Enter it as a decimal (0.032).
      • Sometimes the factor 3.2% is expressed as its inverse (96.8%). Be sure you are entering a single-digit percent (e.g. 0.032, not 0.968). 
  • You may be asked to report the pre-adjustment number, post-adjustment number, or both (depending on your state’s attestation process).

Group 3 States Assumptions

  • The volume attestation is for periods AFTER 1/1/2013 (volume attestations were computed using a different methodology prior to 1/1/2013).  If you are attesting to volume for a period prior to 1/1/2013, this report may not be able to be used.
  • The “encounter” volume methodology is acceptable (as opposed to the “panel” volume methodology, which is not used here).  
  • The reporting practice/providers are not part of a rural health clinic (RHC), federally-qualified health center (FQHC), or another entity that is permitted to use “needy patient volume” rather than strictly Medicaid encounters.
  • “Zero pay claims” are acceptable to include, as long as the patient had Medicaid on the date of service.
  • The practice may include any patient with Medicaid seen during the period, even if it was not the primary insurance on the date of service.
  • The report may use the rendering provider only, rather than double attribution using both rendering and billing provider.
  • The providers only have clinical practices in one state.
  • No out of state Medicaid plans appear in the practice’s “Medicaid Plans SQL” report.
  • This provider (for individuals) all of the providers (for groups) performs no more than 90% of their services in a hospital (place of service 21 or 23).
  • The practice is in a state in which Medicaid expansion funds are used to fund its CHIP program and thus all CHIP eligibles may be included in the encounter volume calculation.  Thus, the practice may include CHIP plan insurance codes in its “Medicaid Plans SQL” report but need not make any “CHIP factor adjustments”.

Group 4 States Assumptions

  • The volume attestation is for periods AFTER 1/1/2013 (volume attestations were computed using a different methodology prior to 1/1/2013). If you are attesting to volume for a period prior to 1/1/2013, this report may not be able to be used.
  • The “encounter” volume methodology is acceptable (as opposed to the “panel” volume methodology, which is not used here).  
  • The reporting practice/providers are not part of a rural health clinic (RHC), federally-qualified health center (FQHC), or another entity that is permitted to use “needy patient volume” rather than strictly Medicaid encounters.
  • “Zero pay claims” are acceptable to include, as long as the patient had Medicaid on the date of service. However, zero pay claims must be individually counted and reported.
  • The practice may include any patient with Medicaid seen during the period, even if it was not the primary insurance on the date of service.
  • The report may use the rendering provider only, rather than double attribution using both rendering and billing provider.
  • The providers only have clinical practices in one state.
  • No out of state Medicaid plans appear in the practice’s “Medicaid Plans SQL” report.
  • This provider (for individuals) all of the providers (for groups) performs no more than 90% of their services in a hospital (place of service 21 or 23).
  • The practice can easily segregate Medicaid eligibles from CHIP eligibles into different OP insurance plans, and CHIP plans do not appear in the practice’s “Medicaid Plans SQL” report. As such, the practice does not need to make any “CHIP factor adjustments’ to the report.

Group 5 States Assumptions

We couldn’t figure out where these states are grouped.  If you need to attest in one for one of the states listed below, please contact your state Medicaid office to find out its rules and share them with OP. Sharing your findings can help us help you find the right attestation report(s).

  • Montana
  • Virginia