1. 1. PROVIDER'S NAME:
2. 2. OSHPD FACILITY NUMBER:
3. 3. MEDICARE PROVIDER NUMBER:

4. 4. CONTACT PERSON AND PHONE NUMBER:

   Hospital Outpatient Department Cost-to-Charge Ratio

   Pursuant to Section 9789.33(c)(4), the cost-to-charge ratio applicable to a hospital outpatient department participating in the Medicare program shall be the hospital's cost-to-charge ratio used by the Medicare fiscal intermediary to determine high cost outlier payments under 42 CFR 419.43(d). List below the cost-to-charge ratio being used by the intermediary for services furnished on February 15 of the year this election is filed:

5. 5. Cost-to-charge ratio

   Signature and Title

   Date

   Ambulatory Surgical Center (ASC) Cost-to-Charge Ratio

   Pursuant to Section 9789.33(c)(5), the cost-to-charge ratio applicable to an ambulatory surgery center shall be the ratio of the facility's total operating costs to total gross charges during the preceding calendar year. Total gross charges is defined as the facility's total usual and customary charges to patients and third-party payers before reductions for contractual allowances, bad debts, courtesy allowances and charity care.

6. 6. Provide:
7. (a) The facility's total operating costs during the preceding calendar year__________
8. (b) The facility's total gross charges during the preceding calendar year __________
9. (c) Provide county where facility is located__________

10. 7. Attach completed Annual Utilization Report of Specialty Clinics (OSHPD) which is incorporated by reference, and may be obtained at OSHPD's website at http://www.oshpd.ca.gov/HID/HID/clinic/util/index.htm#Forms or is available upon request to the Administrative Director at: Division of Workers' Compensation (Attention: OMFS-Outpatient), P.O. Box 71010, Oakland, CA 94612.

    Upon request from the Administrative Director, an independent audit may be conducted at the expense of the ASC.

11. 8. We, the undersigned, declare under penalty of perjury under the laws of the State of California that the foregoing, and attachment(s), are true and correct.

    Signature, Chief Executive Officer

    Date

    Signature, Certified Public Accountant

    Date

    DWC Form 15 (rev. 09/01/2014)

State of California

Department of Industrial Relations

DIVISION OF WORKERS' COMPENSATION

ELECTION FOR HIGH COST OUTLIER

Labor Code § 5307.1; Title 8, California Code of Regulations § 9789.37

This Section 9789.37 is inapplicable for dates of service on or after September 1, 2014.

For the 12 month period commencing on April 1, 20___.

This Election is filed with the Administrative Director pursuant to Labor Code Section 5307.1, and Title 8, California Code of Regulations Section 9789.33. A provider who elects to participate in the alternative payment methodology for high cost outlier cases under Section 9789.33, subdivision (b) in lieu of the maximum allowable fees set forth under Section 9789.33 subdivision (a), shall file this form by March 1 of each year providing the requested information to the Administrative Director. The maximum allowable fees applicable to a facility that does not file a timely election satisfying the requirements set forth in Section 9789.33, subdivision (b), shall be determined under subdivision (a).

Note: Authority cited: Sections 133, 4603.5, 5307.1 and 5307.3, Labor Code. Reference: Sections 4600, 4603.2 and 5307.1, Labor Code.

History

1. New section filed 1-2-2004 as an emergency; operative 1-2-2004 (Register 2004, No. 2). A Certificate of Compliance must be transmitted to OAL by 5-3-2004 or emergency language will be repealed by operation of law on the following day.

2. Certificate of Compliance as to 1-2-2004 order transmitted to OAL 4-30-2004 and filed 6-15-2004 (Register 2004, No. 25).

3. Amendment filed 12-27-2012; operative 1-1-2013 as a file and print only pursuant to Government Code section 11340.9(g) (Register 2012, No. 52).

4. Amendment filed 6-3-2014; operative 9-1-2014 as a file and print only pursuant to Government Code section 11340.9(g) (Register 2014, No. 23).