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New Uniform Thresholds for Determining Low Medicare Utilization Providers

Effective for all cost reports received on or after 6/19/2020, the MACs are instructed to use the following defined “Low Medicare Utilization Thresholds” compared to total reimbursement amounts to determine whether a provider qualifies to file a low utilization cost report in accordance with PRM 15-2, Section 110:

  • FQHCs: $50,000
  • RHCs: $50,000
  • All Other Providers: $200,000. This includes hospital and non-hospital provider types.
  • CMHCs: $0 CMHCs do not qualify for low utilization as they do not have a threshold/limitation for outlier reconciliations. Note 1: Total Reimbursement is the sum of the current interim payments on the PS&R, total bi-weekly payments (including Periodic Interim Payments) and total lump sum adjustments. Note 2: The above thresholds will be applied to the cost report being submitted for the entire provider complex (family). This means if a hospital cost report is being submitted with a provider-based FQHC, the Low Medicare Utilization threshold used will be the $200,000 hospital threshold amount; it will not be $250,000 (which would be the hospital $200,000 threshold plus the FQHC $50,000 threshold).

Posted 6/5/2020


Last Modified: 6/5/20
New Uniform Thresholds for Determining Low Medicare Utilization Providers
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