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Medicaid Patient Volume and Hospital-Based Eligibility

Medicaid Patient Volume: Eligible Professionals (EPs) may choose one (or more) clinical sites of practice to calculate patient volume (i.e., the calculation does not need to be across all of an EP’s sites of practice). However, at least one site at which the EP is adopting or meaningfully using certified EHR technology must be included in the patient volume.

New Hampshire implemented Managed Care Organizations on December 1, 2013. EPs and EHs attesting for a 2014 payment using patient volume from the last quarter of 2013 (October – December 2013) should use Medicaid encounters for October and November and Medicaid plus Medicaid Managed Care Organization encounters for December.

New Hampshire Managed Care Organizations include Well Sense; Meridian; and NH Healthy Families.

  • Patient Volume reporting period: any continuous 90-day period during the prior calendar year.
  • Total encounters (denominator): all encounters that the EP provided during the Patient Volume reporting period.
  • Medicaid encounters (numerator): all services (in the denominator) provided in a day by a specific provider to a Medicaid-enrolled individual during the Patient Volume reporting period. This includes:

(Definition for January 1 through November 30, 2013)

  • Services in which Medicaid or out-of-state Medicaid or out-of-state Medicaid Managed Care programs paid for part or all of the services (including premiums, co-payments, and/or cost sharing); or
  • Encounters where Medicaid paid zero dollars where Medicare (in the case of patients that are dually eligible for both Medicaid and Medicare) or another third party paid for the encounter; or
  • Encounters provided to Medicaid beneficiaries for which no payments were received; or
  • Medical services provided to Medicaid beneficiaries that were not covered under New Hampshire's Medicaid program.

(Definition for December 1, 2013 through December 31, 2013)

  • Services in which Medicaid or Medicaid Managed Care programs (including out-of-state programs) paid for part or all of the services (including premiums, co-payments, and/or cost sharing); or
  • Encounters where Medicaid paid zero dollars where Medicare (in the case of patients that are dually eligible for both Medicaid and Medicare) or another third party paid for the encounter; or
  • Encounters provided to Medicaid beneficiaries for which no payments were received; or
  • Medical services provided to Medicaid beneficiaries that were not covered under New Hampshire's Medicaid program.

Examples of encounters that CAN be included are:

  • Claims denied due to service limitation audits;
  • Claims denied due to non-covered services;
  • Claims denied due to timely filing; and
  • Services rendered on Medicaid members that were not billed due to the provider's understanding of Medicaid business rules.

Examples of encounters that CANNOT be included are:

  • Claims denied due to the provider being ineligible for the date of service; and
  • Claims denied due to the member being ineligible for the date of service.

Hospital-Based Eligibility: Eligible Professionals that report Medicaid patient volume cannot be hospital-based. 90 percent or less of their Medicaid encounters must have occurred outside of a hospital setting during the prior calendar year.

  • Hospital-based reporting period: 365-days during the prior calendar year.
  • Total Medicaid encounters (denominator): total Medicaid encounters during the hospital-based reporting period.
  • Medicaid Hospital-based encounters (numerator): the sum of Medicaid inpatient encounters (Place of Service 21) and Medicaid emergency department encounters (Place of Service 23) during the hospital-based reporting period.
 
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New Hampshire Department of Health and Human Services
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