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§ 495.306 Establishing patient volume.

(a) A Medicaid provider must annually meet one of the following to establish patient volume:

(1)  (i) General rule for a professional. Except as specified in paragraph (a)(1)(ii) of this section, a Medicaid EP must attest that a minimum of 30 percent of his or her patient encounters over any continuous 90-day period in the most recent calendar year was covered by Medicaid.

(ii) Optional exception.

(A) A pediatrician must attest that a minimum of 20 percent of his or her patient encounters over any continuous 90-day period in the most recent calendar year was covered by Medicaid.

(B) A Medicaid EP practicing predominantly in a Federally Qualified Health Center or Rural Health Clinic must attest that a minimum of 30 percent of his or her patient encounters over any continuous 90-day period in the most recent calendar year was with needy individuals as defined in §495.302 of this subpart.

(2) General rule for an acute care hospital. An acute care hospital must attest that a minimum of 10 percent of all patient encounters over any continuous 90-day period in the most recent calendar year was covered by Medicaid.

(b) If a State has an alternative approach to the established timeframe for measuring patient volume, the State must submit the approach to CMS for review and prior approval. CMS determines if it is an acceptable alternative.

(1) To be considered for approval, the alternative approach must be justified and have a verifiable data source.

(2) If CMS approves the State's alternative approach to the established timeframe for measuring patient volume, such timeframe would apply to Medicaid EPs and eligible hospitals, instead of the 90-day timeframe described in paragraph (a) of this section.

(c) To establish patient volume for an EP who practices predominantly in a Federally Qualified Health Center or Rural Health Clinic by use of uncompensated care data, an adjustment to the uncompensated care data must be completed so that it is an appropriate proxy for charity care, including a downward adjustment to eliminate bad debt data from uncompensated care.

(d) An individual enrolled in a managed care organization, pre-paid inpatient health plan, or pre-paid ambulatory health plan under part 438 of this chapter must be included in the calculation to establish patient volume.

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