Health Facility Cash Assessment Program

Instructions for Completing Reporting Forms

Hospital Quality Contribution (HQC)

General Instructions

The electronic report is to be used on a monthly basis to calculate the Hospital Quality Contribution (HQC). This report should be submitted even if there were no inpatient obstetrical patient care services for the reporting month. ONLY INCLUDE AMOUNTS BILLED ON BEHALF OF THE HOSPITAL AND NOT FOR PRIVATE PHYSICIAN BILLINGS OR AFFILATION AGREEMENTS.

Columnar Descriptions

Description. Itemize total cash receipts by maternity services and normal newborn services.

Current Month. Report the current month´s cash receipts.

Linear Descriptions

Line 1a AND Line 1b. - CASH RECEIVED FROM INPATIENT OBSTETRICAL PATIENT CARE SERVICES Enter ALL CASH RECEIPTS (and/or checks) received during the month. Cash receipts include but are not limited to payments received from Medicaid, Medicare, Blue Cross and Blue Shield, other insurance payors, Worker´s Compensation, and self-payors. Receipts are assessable in the month they are received irrespective of the service date or billing period (cash basis).

The following APR-DRGs or equivalent under a comparable classification system should be subject to the contribution:

1a. Maternity Services

540 Cesarean Delivery

541 Vaginal Delivery with Sterilization and/or Dilation and Curettage

542 Vaginal Delivery with Complicating Procedures Excluding Sterilization and/or Dilation and Curettage

560 Vaginal Delivery

1b. Normal Newborn Services

640 Normal Newborn

Line 1 - This calculates Total Cash Receipts: Line 1a plus Line 1b.Line 4 less Line 5.

Line 2 - Assessment Rate: The applicable assessment rate for a given report period.

Line 3 - Current Month Assessment: This Multiplies Line 1 by Line 2.

Line 4 - Other Adjustments: Report adjustments due to errors or omissions in prior months and to report a credit for a prior month. Adjustments may be either a positive or negative. Specify the month for the adjustment , the applicable assessment rate, and the reason(s) for the adjustment. If the adjustment is for multiple months, attach a detailed schedule. Detailed records should be maintained as all data is subject to audit.

Line 5 - Amount Due: This adds Line 4 plus Line 5. If the amount is negative (a credit amount), it is automatically reported on Line 6. Otherwise, remit this amount to the Assessment Fund Administrator.

Line 6 - Excess Credit for Future Remittance: This calculates the credit amounts, if any, from Line 5 and carries it forward to Line 4 of next month´s report.