Upper Payment Limit FAQs
To date, CMS has not published a list of revenue codes that must be included or excluded from this service category. Medicaid outpatient hospital services are defined at 42 Code of Federal Regulations (CFR) 440.20 and include “preventive, diagnostic, therapeutic, rehabilitative, or palliative services”. In the state plan, states further define those services covered as outpatient hospital services.
The UPL data for out of state providers does not need to be included in the UPL demonstration. If the state has provider level data then it may include it in the demonstration within the private ownership category of providers.