FFY 2004 and Earlier SSI Elections - JE Part A

CMS issued Change Request (CR) 10484 which provided instruction to hospitals on the election of a Medicare Supplemental Security Income (SSI) component of the Disproportionate Share (DSH) payment adjustment for cost reports that involve SSI ratios for fiscal year (FY) 2004 and earlier.

Before Noridian can process an initial NPR or a revised NPR pursuant to CMS Ruling 1498-R the hospital must first submit a written request electing the basis for which they would like their SSI ratio calculated. Hospitals may elect either:

• to include inpatient days of a person entitled to Medicare Part A in the numerator (if the patient was also entitled to SSI) and denominator of the SSI fraction, even if the inpatient stay was not covered under Part A or if the patient's Part A hospital benefits were exhausted (total days), or
• to exclude inpatient days of a person entitled to Medicare Part A in the numerator (if the patient was also entitled to SSI) and denominator of the SSI fraction (covered days)

The election is available for hospital cost reporting periods where Noridian has not yet final settled the provider's Medicare cost report, as well as appeals remanded to the contractor pursuant to CMS Ruling 1498-R (assuming any such hospital cost reporting period involves SSI ratios for federal fiscal year 2004 and earlier or SSI ratios for hospital cost reporting periods, but only for those patient discharges occurring before Oct. 1, 2004)

The written request must be received by Noridian within 180 calendar days from that date these instructions were posted to the Noridian website. The written request must include all of the following information:

• Provider Number
• Hospital Name
• PRRB Case Number and PRRB Remand Date (if applicable)
• Case Name, Docket Number (if applicable)
• Hospital's designated representative (if applicable)
• Cost Report Begin Date (YYYYMMDD)
• Cost Report End Date (YYYYMMDD)
• FFY Based on CY Begin Date (YYYY)
• Provider Election ("Total" or "Covered")
• SSI ratio selected (Numerical value from CMS website) Disproportionate Share Hospital (DSH)

In order to facilitate the processing of your election Noridian asks that your written election be submitted electronically to the following address: SSIremandelections@noridian.com

We also ask that you include a copy of any applicable remand notice with your written election. Any additional questions regarding this should be sent to the SSIremandelections@noridian.com mailbox.