Practitioner Upper Payment Limit (UPL) also known as Enhanced Rates for Practitioner Services delivered in a teaching environment.
|In order to ensure access to practitioner services by needy
individuals in the State of Nevada and to recognize the higher cost of
providing practitioner services in a teaching environment, the Practitioner
UPL program participants receive a quarterly supplemental payment for
outpatient Fee-for-Service claims in addition to the Medicaid Base Rate(s)
normally paid for said services. The formula for calculating these payments
is authorized pursuant to the Medicaid State Plan Attachment
4.19 B, Pages 8 and 9.
Quarterly Calculation Timeline:
The timeline that follows is based upon the state plan and was created to give a tracking mechanism for due dates and when information is to be provided by the State of Nevada as well as when information is required from the facilities.
Calculations are based on a state fiscal year:
Calculations are processed after the quarter closes. Timeline document below considers the processing of claims using the closed quarter.
Yearly Average Commercial Rate (ACR) Reporting by Participating Facilities
Average Commercial Rate (ACR):
The ACR is calculated by taking into account each procedure (HCPCS/CPT/CDT) code and reimbursement amount from the reported top five commercial payers to the public teaching entity, then averaged. "Commercial payers" exclude Medicare, Workers Compensation, and any other payer(s) not subject to market forces. The ACR for each procedure code is established separately for each public teaching entity every Base Period. ACR is to be completed using the standard format template which can be requested from the Supplemental Reimbursement Unit (SRU) or accessed on the forms section of the website. Once completed the ACR should be submitted to the SRU each year by the first business day in August.
Average Commercial Rate (ACR) Reporting:
1st Business day of August - Using the standard format (under forms), each public teaching entity will supply the ACR each year by the first business day of August for the base period (Previous State Fiscal Year (SFY) July 1-June 30)