Broadlawns Medical Center Sample Clauses

Broadlawns Medical Center. The purpose of this funding is for durable medical equipment and pharmacy services provided to IowaCare members assigned to Broadlawns as a medical home and is limited to outpatient prescription drugs, beyond the current 10-day supply of prescription medication after an inpatient hospital discharge that is included in the benefit package for all IowaCare members.
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Broadlawns Medical Center a. Methodology for those services in which costs would not be reported on neither the Medicare or Medicaid cost report (includes services such as optometry, podiatry and durable medical equipment) Each covered procedure shall be billed and priced according to the methodology under the most Attachment A IowaCare Special Terms and Conditions Methods and Standards for Establishing Payment Rates for IowaCare Services current approved Medicaid State plan in effect as of the date of service submitted on the claim. At the end of each state fiscal year, a provider-specific basis comparison between payments received for services provided to IowaCare members and the actual cost of providing the service to IowaCare members (less any payment received by or on behalf of such individual for such services) shall be completed. Because these service providers do not currently complete a Medicare or Medicaid cost report the actual cost cannot be determined. Therefore, the following process will be used to determine a proxy for the cost of providing the service instead of actual cost. The cost of providing the service shall be calculated at the claim level. For all paid claims, the allowable charge submitted on the claim shall be multiplied by an appropriate cost to charge ratio to determine a proxy for the cost of providing the service. The proxy costs calculated for each claim shall be summed to determine the total proxy cost of providing the service. The total proxy cost is then compared to the total payments made to the provider for the same set of claims and service. The total payment is the sum of IowaCare payment plus any payment received by or on behalf of such individual for such services received. The cost to charge ratio shall be determined based on review of financial data submitted by the service provider. If possible a separate cost to charge ratio will be established for each type of service. If financial data is not detailed enough an overall cost to charge ratio will be determined and applied to all claims.

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