[Code of Federal Regulations] [Title 42, Volume 2] [Revised as of October 1, 2002] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR413.180] [Page 605-607] TITLE 42--PUBLIC HEALTH HUMAN SERVICES PART 413--PRINCIPLES OF REASONABLE COST REIMBURSEMENT; PAYMENT FOR END-STAGE RENAL DISEASE SERVICES; PROSPECTIVELY DETERMINED PAYMENT RATES FOR SKILLED NURSING FACILITIES--Table of Contents Subpart H--Payment for End-Stage Renal Disease (ESRD) Services and Organ Procurement Costs Sec. 413.180 Procedures for requesting exceptions to payment rates. (a) Outpatient maintenance dialysis payments. All payments for outpatient maintenance dialysis furnished at or by facilities are made on the basis of prospective payment rates. (b) Criteria for requesting an exception. If a facility projects on the basis of prior year costs and utilization trends that it will have an allowable cost per [[Page 606]] treatment higher than its prospective rate set under Sec. 413.174, and if these excess costs are attributable to one or more of the factors in Sec. 413.182, the facility may request, in accordance with paragraph (d) of this section, that CMS approve an exception to that rate and set a higher prospective payment rate. However, a facility may only request an exception or seek to retain its previously approved exception rate when authorized under the conditions specified in paragraphs (d) and (e) of this section. (c) Application of deductible and coinsurance. The higher payment rate is subject to the application of deductible and coinsurance in accordance with Sec. 413.176. (d) Payment rate exception request. A facility must request an exception to its payment rate within 180 days of-- (1) The effective date of its new composite payment rate(s); (2) The effective date that CMS opens the exceptions process; or (3) The date on which an extraordinary cost-increasing event occurs, as specified (or provided for) in Secs. 413.182(c) and 413.188. (e) Criteria for retaining a previously approved exception rate. A facility may elect to retain its previously approved exception rate in lieu of any composite rate increase or any other exception amount if-- (1) The conditions under which the exception was granted have not changed; (2) The facility files a request to retain the rate with its fiscal intermediary during the 30-day period before the opening of an exception cycle; and (3) The request is approved by the fiscal intermediary. (f) Documentation for a payment rate exception request. If the facility is requesting an exception to its payment rate, it must submit to CMS its most recently completed cost report as required under Sec. 413.198 and whatever statistics, data, and budgetary projections as determined by CMS to be needed to adjudicate each type of exception. CMS may audit any cost report or other information submitted. The materials submitted to CMS must-- (1) Separately identify elements of cost contributing to costs per treatment in excess of the facility's payment rate; (2) Show that the facility's costs, including those costs that are not directly attributable to the exception criteria, are allowable and reasonable under the reasonable cost principles set forth in this part; (3) Show that the elements of excessive cost are specifically attributable to one or more conditions specified in Sec. 413.182; (4) Specify the amount of additional payment per treatment the facility believes is required for it to recover its justifiable excess costs; and (5) Specify that the facility has compared its most recently completed cost report with cost reports from (at least 2) prior years. The facility must explain any material statistical data or cost changes, or both, and include an explanation with the documentation supporting the exception request. (g) Completion of requirements and criteria. The facility must demonstrate to CMS's satisfaction that the requirements of this section and the criteria in Sec. 413.182 are fully met. The burden of proof is on the facility to show that one or more of the criteria are met and that the excessive costs are justifiable under the reasonable cost principles set forth in this part. (h) Approval of an exception request. An exception request is deemed approved unless it is disapproved within 60 working days after it is filed with its intermediary. (i) Determination of an exception request. In determining the facility's payment rate under the exception process, CMS excludes all costs that are not reasonable or allowable under the reasonable cost principles set forth in this part. (j) Period of approval: Payment exception request. Except for exceptions approved under Secs. 413.180(e), 413.180(k), 413.182(c), and 413.188, a prospective exception payment rate approved by CMS applies for the period from the date the complete exception request was filed with its intermediary until the earlier of the-- (1) Date the circumstances justifying the exception rate no longer exist; or [[Page 607]] (2) End of the period during which the announced rate was to apply. (k) Period of approval: Payment exception request under Secs. 413.182(c) and 413.188. A prospective exception payment rate approved by CMS under Secs. 413.182(c) and 413.188 applies from the date of the extraordinary event until the end of the period during which the prospective announced rate was to apply, unless CMS determines that another date is more appropriate. If CMS does not extend the exception period and the facility believes that it continues to require an exception to its rate, the facility must reapply in accordance with the procedures in this section. (l) Denial of an exception request. CMS denies exception requests submitted without the documentation specified in Sec. 413.182 and the applicable regulations cited there. (m) Criteria for refiling a denied exception request. A facility that has been denied an exception request during the 180 days may file another exception request if all required documentation is filed with the intermediary by the 180th day.