Post-Payment Audit Guidance


A hospital–based provider is defined as a provider who furnishes 90% or more of his/her covered Medicaid services in either inpatient (code 21) or emergency department (code 23) of a hospital. Hospital–based providers do not qualify for Medicare or Medicaid Electronic Health Record incentive payments. This determination is based solely on the individual provider's covered Medicaid services during the calendar year immediately preceding the payment year. For example, a provider attesting to payment year (PY) 2014 would make this determination based on his/her total covered Medicaid inpatient and emergency department services against his/her total covered Medicaid services for the 2013 calendar year (1/1/13 – 12/31/13). Non–Medicaid encounters are not included in the hospital–based determination.

During the attestation process, providers are asked to confirm if they are hospital–based with a yes or no answer. Providers are strongly urged to consider the meaning of being a hospital–based provider when attesting.