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FAQ Data Descriptions Costs 

Select the Frequently Asked Question to view answer.
  1. What is a claim?
    In most cases, a claim is a request for payment from a healthcare facility or provider for healthcare services rendered to a benefits recipient.
  2. Is claims-level data included in the data sets?
    Claims level data is not included in Data Set I. Data Set II will add claims-level data for in-patient, long-term care, emergency room, and prescription drug claims. Data Set I instead provides summarized claims data. Claims are summarized by Type of Service and within Type of Service by events, units, and total costs.
  3. How are costs calculated?
    Cost information in the data sets does not reflect the total cost of services or the process by which costs are set. Rather, the cost data included in the data sets reflects the net liability of Medicaid. In other words, wherever relevant, it reflects the cost of the claim after any cost-reducing negotiations with the healthcare providers; after any private insurance has paid the claim; and/or after Medicare has contributed the portion for which it has liability. The costs therefore reflect the net liability of Medicaid towards charges it deems reasonable and customary.
  4. Are non-claims payments included in the data sets?
    Non-claims payments refer to payments that cannot be linked to a specific service(s), on a specific date(s), or for a specific recipient, and are not paid through our claims system.

    Some data on non-claims payments is included in the data sets, but this information is not the comprehensive total of all non-claims payments Healthcare and Family Services (HFS) may make to a provider. Non-claims payments are found in the data sets as encounter claims; add-on payments; and capitation payments to Managed Care Organizations (MCOs), Federally Qualified Health Centers (FQHC) for their Managed Care-enrolled populations, and Primary Care Case Management (PCCM) organizations.
  5. What are add-on payments?

    Add-on (supplemental or ‘kick’) payments are payments to hospitals to augment the fees paid per service by managed care organizations.

    These payments affect the claims for service accessed by approximately 7,300 of the 2.8 million recipients in our file. These payments affect claims for inpatient care, including labor and delivery.

    Claims are in the CCIP data sets in the costs category. Add-on payments are included as a separate data point. Both are included in Total Costs.

  6. What are encounter claims, and how are they included in the data sets?
    Encounter claims refer to documentation of services provided by a Managed Care Organization (MCO) that receives a capitation payment from Healthcare and Family Services (HFS). In this case, a ‘claim’ is not defined as ‘a request for payment from a healthcare facility or provider for healthcare services rendered to a benefits recipient.’ Rather, ‘encounter claim’ is a euphemistic term for notification of the provision of services to the recipients enrolled in the MCO. These will appear in our data sets with the payment amount equal to $0.
  7. Are encounter rate claims included in the data sets?
    Encounter rate claims refer to claims made by organizations that Healthcare and Family Services (HFS) pays a fixed price for each service, regardless of the specifics of that service. Federally qualified healthcare centers are paid on such a basis. These claims are a subset of total claims and are usually included in total claim counts and payments.
  8. Are Disproportionate Share payments in the data sets?

    Disproportionate Share payments to Hospitals (DSH payments) are intended to provide additional revenue to the hospitals that routinely treat a greater-than-average number of Medicaid patients. These hospitals receive set sums of money from Healthcare and Family Services (HFS), calculated based on the cost of care for Medicaid and charity care patients. Managed Care Organizations (MCOs) and other healthcare organizations do not receive DSH payments.

    DSH payments are included in the net liability of the specific claims to which they were added.

  9. What does ‘Total Costs’ represent?

    What does ‘Total Costs’ represent?

    The Total Costs column totals all the preceding categories that include the word ‘cost.’ This includes add-on payments, Disproportionate Share to Hospitals (DSH) payments, and all other payments for services. It includes capitation payments to Managed Care Organizations (MCOs), Federally Qualified Health Centers (FQHCs), Primary Care Case Management (PCCM), or any other organization paid via capitation.

  10. If payments for services change in the near future, how will this affect the CCE/MCCN selections, negotiations and contracts?
    Rate reforms are underway. We expect to publish updates as necessary to reflect the impact reforms may have on the care coordination process. Changes to payment rates that occur after the Solicitation period will be incorporated in the negotiation process for contracted Care Coordination Entities (CCEs) and Managed Care Community Network (MCCNs).