The Medicaid Provider Profile page shows the Medicaid services provided by your facility, along with the values and effective dates of Medicaid reimbursement calculations.
- To access the Medicaid Provider Profile page, select Go To > Government Payor Research > Medicaid > Provider Profile. The Medicaid Provider Profile page opens.
- In the Select State or Payer drop down list, select Other.
- Select Go.
- Select the state for the provider you want to review from the State list.
- Enter the provider’s tax ID or ten-digit National Provider Identification (NPI) number for the provider you want to review in the NPI or Provider Number field.
- Enter a date in the Effective Date field if you want to view provider profile information for an effective date other than today.
- Click Display Profile. The Medicaid Provider Profile information displays.
Note: To clear the results and return to original Medicaid Provider Profile page, click Reset.
- Review your Medicaid Provider Profile information.
Note: The data that displays on the provider profile varies from state to state.
California Medicaid Provider Profile
The following table describes each of the fields on the Medicaid Provider Profile page for Medi-Cal.
|
Field |
Description |
|
Selection Criteria |
|
|
State or Payer |
State or payer for the selected provider number |
|
NPI or Provider Number |
Provider’s tax ID number or ten-digit National Provider Identification (NPI) number required on all claims |
|
Effective Date |
Date on which the selected profile went into effect |
|
Inpatient Acute APR-DRG Hospital |
|
|
Item |
Specific line item |
|
Value |
Value of the line item |
|
Effective Date |
Date on which the selected item went into effect |
|
Inpatient Acute Hospital |
|
|
Item |
Specific line item |
|
Value |
Value of the line item |
|
Effective Date |
Date on which the selected item went into effect |
|
REV Code |
Revenue Code |
|
Per Diem |
Amount reimbursed per day |
|
Effective Date |
Date on which the selected revenue code went into effect |
|
Outpatient Acute Hospital |
|
|
Item |
Specific line item |
|
Value |
Value of the line item |
|
Effective Date |
Date on which the selected item went into effect |
Washington DC Medicaid Provider Profile
The following table describes each of the fields on the Medicaid Provider Profile page for Washington DC Medicaid.
|
Field |
Description |
|
State or Payer |
State or payer for the selected provider number |
|
NPI or Provider Number |
Provider’s tax ID number or ten-digit National Provider Identification (NPI) number required on all claims |
|
Effective Date |
Date on which the selected profile went into effect |
|
EAPG |
|
|
Base Rate |
State determined, Facility specific Base Rate used for standard EAPG Payment |
|
User Defined Adjustment Factor |
Facility specific adjustment factor for payments. |
Colorado Medicaid Provider Profile
The following table describes each of the fields on the Medicaid Provider Profile page for Colorado Medicaid.
|
Field |
Description |
|
State or Payer |
State or payer for the selected provider number |
|
NPI or Provider Number |
Provider’s tax ID number or ten-digit National Provider Identification (NPI) number required on all claims |
|
Effective Date |
Date on which the selected profile went into effect |
|
EAPG |
|
|
Base Rate |
State determined, Facility specific Base Rate used for standard EAPG Payment |
|
User Defined Adjustment Factor |
Facility specific adjustment factor for payments. |
|
Value |
Value of the line item |
|
Effective Date |
Date on which the selected item went into effect |
Florida Medicaid Provider Profile (prior to 07/01/2022)
The following table describes each of the fields on the Medicaid Provider Profile page for Florida Medicaid prior to 07/01/2022.
|
Field |
Description |
|
State or Payer |
State or payer for the selected provider number. |
|
NPI or Provider Number |
Provider’s tax ID number or ten-digit National Provider Identification (NPI) number required on all claims. |
|
Effective Date |
Date on which the selected profile went into effect. |
|
APR |
|
|
Standard Base Rate |
The agency defined beginning dollar amount per claim before any adjustments are made. |
|
Automatic Inter Governmental Transfer Add-on |
Hospital specific additional claim payment amount for Inter-Governmental Transfers. This amount is adjusted for each claim payment. |
|
Cost to Charge Ratio |
Hospital specific factor representing the proportion of the claim covered charges that are to be attributed to the costs. This factor is used to estimate the cost of the claim for determining whether the hospital's inpatient claim exceeds the cost outlier threshold. |
|
Provider Casemix |
Hospital specific value that is the average relative weight of all claims in a specific time frame. |
|
Trauma Supplemental Payment Adjustor |
The representation of the trauma supplemental payment percentage in a decimal format. |
|
Age Limit for Adjustment |
The age in years which, if the patient's age is less than, makes the claim eligible for an age adjustment. |
|
Cost Outlier Threshold |
The dollar amount the claim costs minus the standard (or transfer) and IGT payments exceed, qualifies the claim for cost outlier reimbursement. |
|
High Cost Factor |
The decimal representation of the percent reimbursement of costs exceeding the claim's cost outlier threshold. |
|
High Cost Factor Pediatric Neonate with High SOI |
The decimal representation of the percent reimbursement of costs exceeding a claim's cost outlier threshold - specific to pediatric and neonate claims with high SOI. |
|
High Medicaid High Outlier Provider Adjustor |
The decimal representation of the percent adjustment made to a claim from a facility with a high proportion of Medicaid and/or costly claims. |
|
Long Term Acute Care Provider Adjustor |
The decimal representation of the percent adjustment made to a claim from a Long Term Care facility. |
|
Rehabilitation Provider Adjustor |
The decimal representation of the percent adjustment made to a claim from a Rehabilitation facility. |
|
Rural Provider Adjustor |
The decimal representation of the percent adjustment made to a claim from a Rural facility. |
|
Outpatient Acute Hospital |
|
|
Effective Date |
Date on which the selected item went into effect. |
|
Item |
Specific line item. |
|
Value |
Value of the line item. |
|
EAPG |
|
|
Base Rate |
Base rate used for standard EAPG payment. |
|
Provider Policy Adjustor |
Line level adjustment to increase payment for certain providers such as rural and high medicaid outpatient utilization hospitals. |
|
Per Service Automatic Rate |
Fixed payment for each service line even if the service consolidates or packages. Does not apply to denied lines. Not applicable for ASC facilities. |
|
Outpatient Lab Fee Schedule |
|
|
CPT |
CPT code for the line item. |
|
Effective Date |
Date on which the selected item went into effect. |
|
Max Units |
The maximum number of units that can be associated with the line item. |
|
Rate |
The individual rate associated with the line item. |
Florida Medicaid Provider Profile (effective 07/01/2022)
The following table describes each of the fields on the Medicaid Provider Profile page for Florida Medicaid effective 07/01/2022.
|
Field |
Description |
|
State or Payer |
State or payer for the selected provider number. |
|
NPI or Provider Number |
Provider’s tax ID number or ten-digit National Provider Identification (NPI) number required on all claims. |
|
Effective Date |
Date on which the selected profile went into effect. |
|
APR |
|
|
DRG Base Rate |
Provider-specific beginning dollar amount per claim before any adjustments are made. This base rate accounts for any applicable adjustments for minimum wage increases and Hospital Outlier Payments. |
|
Cost to Charge Ratio |
Hospital specific factor representing the proportion of the claim covered charges that are to be attributed to the costs. This factor is used to estimate the cost of the claim for determining whether the hospital's inpatient claim exceeds the cost outlier threshold. |
|
Provider Casemix |
Hospital specific value that is the average relative weight of all claims in a specific time frame. |
|
Trauma Supplemental Payment Adjustor |
The representation of the trauma supplemental payment percentage in a decimal format. |
|
Provider Policy Adjustor |
Facility-specific adjustor used in calculation of standard payment. |
|
Per DRG Childrens Hospital Add-on |
Hospital-specific average amount used to calculate the children's hospital add-on payment, for providers that qualify. |
|
Cost Outlier Threshold |
The dollar amount the claim costs minus the standard (or transfer) and IGT payments exceed, qualifies the claim for cost outlier reimbursement. |
|
High Cost Factor |
The decimal representation of the percent reimbursement of costs exceeding the claim's cost outlier threshold. |
|
High Cost Factor Pediatric Neonate with High SOI |
The decimal representation of the percent reimbursement of costs exceeding a claim's cost outlier threshold - specific to pediatric and neonate claims with high SOI. |
|
Age Limit for Adjustment |
The age in years which, if the patient's age is less than, makes the claim eligible for an age adjustment. |
|
Outpatient Acute Hospital |
|
|
Effective Date |
Date on which the selected item went into effect. |
|
Item |
Specific line item. |
|
Value |
Value of the line item. |
|
EAPG |
|
|
Base Rate |
Base rate used for standard EAPG payment. |
|
Provider Policy Adjustor |
Line level adjustment to increase payment for certain providers such as rural and high medicaid outpatient utilization hospitals. |
|
Per Service Children’s Hospital Add-on Payment |
Add-on payment for services provided in children's hospitals. |
|
Outpatient Lab Fee Schedule |
|
|
CPT |
CPT code for the line item. |
|
Effective Date |
Date on which the selected item went into effect. |
|
Max Units |
The maximum number of units that can be associated with the line item. |
|
Rate |
The individual rate associated with the line item. |
Minnesota Medicaid Provider Profile
The following table describes each of the fields on the Medicaid Provider Profile page for Minnesota Medicaid.
|
Field |
Description |
|
State or Payer |
State or payer for the selected provider number |
|
NPI or Provider Number |
Provider’s tax ID number or ten-digit National Provider Identification (NPI) number required on all claims |
|
Effective Date |
Date on which the selected hospital data is effective |
|
Inpatient Acute Hospital |
|
|
Wage Adjusted Base Rate |
Wage adjusted base rate as determined by the Minnesota administrative code |
|
Disproportionate Share Payment Factor |
Displays the disproportionate share payment factor determined by the Minnesota administrative code |
|
Provider Type |
Displays the type of provider associated with the profile |
|
Cost-to-Charge Ratio |
The ratio for determining hospital cost based on charges |
|
Per Diem Rate |
Amount reimbursed per day |
|
Out of State Hospital |
Indicates if this is an out of state hospital |
|
Fixed Outlier Threshold |
Displays the fixed outlier threshold determined by the Minnesota administrative code |
|
Provider Tax Percentage |
Displays the provider tax percentage |
|
Statewide Average CTC |
Displays the statewide average cost to charge (CTC) |
|
MERC Per Diem Add-on |
Displays the hospital specific per diem add-on for critical access hospitals that qualify for medical education and research cost (MERC) fund. |
|
MERC Adjustor |
Displays the hospital specific payment adjustor for prospective payment system (PPS) hospitals that qualify for medical education and research (MERC) fund. |
|
Operating Rate Per Admission |
MA rate per admission as calculated based on Minnesota Legislation. |
|
Metro Operating Rate Per Admission |
MA Metropolitan Statistical Area (MSA) rate per admission as calculated based on Minnesota Legislation. |
|
Property Cost Per Admission |
MA property cost per admission as calculated based on Minnesota Legislation. Inpatient hospital costs, including depreciation, interest, rents and leases, property taxes, and property insurance. |
|
Metro Property Cost Per Admission |
MA Metropolitan Statistical Area (MSA) property cost per admission as calculated based on Minnesota Legislation. Inpatient hospital costs, including depreciation, interest, rents and leases, property taxes, and property insurance. |
|
Neonatal Cost Per Admission |
MA neonatal rate per admission as calculated based on Minnesota Legislation. |
|
Outlier Rate Per Day |
MA day outlier payment as calculated based on Minnesota Legislation. MHCP will pay a hospital for day outliers in addition to the applicable rate per admission. |
|
Disproportionate Population Adjustment |
Disproportionate population adjustment (DPA) as calculated based on Minnesota Legislation. A hospital-specific adjustment based on MA and low income utilization rates. Note: DPA is also known as disproportionate share hospital (DSH). |
|
Cost-to-Charge Ratio |
The ratio for determining hospital cost based on charges |
New York Medicaid Provider Profile
The following table describes each of the fields on the Medicaid Provider Profile page for New York Medicaid.
|
Field |
Description |
|
State or Payer |
State or payer for the selected provider number |
|
NPI or Provider Number |
Provider’s tax ID number or ten-digit National Provider Identification (NPI) number required on all claims |
|
Effective Date |
Date on which the selected profile went into effect |
|
Inpatient Acute |
|
|
Medicaid Base Rate |
Base rate for inpatient services as determined by the New York administrative code |
|
Managed Medicaid Base Rate |
Managed Medicaid base rate for inpatient services as determined by the New York administrative code |
|
Alternate Level Per Diem |
Per diem reimbursement for alternate level of care services as determined by the New York administrative code |
|
Capital Cost Rate |
Reimbursement rate for additional payment based on capital expenses as outlined in the New York Administrative Code |
|
Capital Cost Per Diem Rate |
Per diem reimbursement rate for additional payment based on capital expenses as outlined in the New York Administrative Code |
|
NY GME Enhance Per Dischg Rate |
Facility-specific Graduate Medical Education (GME) adjustment for teaching hospitals |
|
Cost-to-Charge Ratio |
The ratio for determining hospital cost based on charges |
|
Outpatient Acute |
|
|
EAPG Version |
EAPG version active for the selected provider profile for the effective date |
Pennsylvania Medicaid Provider Profile
The following table describes each of the fields on the Medicaid Provider Profile page for Pennsylvania Medicaid.
|
Field |
Description |
|
State or Payer |
State or payer for the selected provider number |
|
NPI or Provider Number |
Provider’s tax ID number or ten-digit National Provider Identification (NPI) number required on all claims |
|
Effective Date |
Date on which the selected profile went into effect |
|
APR |
|
|
DRG Base Rate |
DRG base rate as determined by the Pennsylvania Administrative Code |
|
Drug and Alcohol Approved |
Indicator of whether the provider is an approved facility for drug and alcohol treatment |
|
CTC Ratio |
The ratio for determining hospital cost based on charges |
|
Psych Unit |
Indicator of whether the provider is a psychiatric facility; valid values are Yes or No |
Washington Medicaid Provider Profile
The following table describes each of the fields on the Medicaid Provider Profile page for Washington Medicaid.
|
Field |
Description |
|
State or Payer |
State or payer for the selected provider number |
|
NPI or Provider Number |
Provider’s tax ID number or ten-digit National Provider Identification (NPI) number required on all claims |
|
Effective Date |
Date on which the selected profile went into effect |
|
Outpatient Acute Hospital |
|
|
Outpatient Ratio of Costs-to-Charges |
The facility-specific outpatient charges by revenue center converted to costs using a cost-to-charge ratio for each revenue center |
|
OPPS Rate |
Outpatient Prospective Payment System base rate as determined by the Washington state administrative code |