Independent Rural Health Center/Freestanding Federally Qualified Health Center Cost Report and Supp. Regs in 42 CFR Sections 413.20 and 413.24 (CMS-222)

Independent Rural Health Center/Freestanding Federally Qualified Health Center Cost Report and Supp. Regs in 42 CFR Sections 413.20 and 413.24

CMS-222 forms-t7.xls

Independent Rural Health Center/Freestanding Federally Qualified Health Center Cost Report and Supp. Regs in 42 CFR Sections 413.20 and 413.24 (CMS-222)

OMB: 0938-0107

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Overview

Notes
WS-S part I^
WS-S part III^
A,p1^
A,p2^
A-1
A-2
A-2-1
B-Part I&II^
C-Part 1^
C-Part II
Sup. B-1


Sheet 1: Notes

^ Indicates revised worksheets in current transmittal.

Sheet 2: WS-S part I^

01-05

Form CMS 222-92

2990 (Cont.)
This report is required by law (42 USC. 1395g: CFR 413.20(b)). Failure to report can result




FORM APPROVED
in all payments made during the reporting period being deemed overpayments (42 USC 1395g).




OMB NO: 0938-0107
INDEPENDENT RURAL HEALTH CLINIC/FREESTANDING


PROVIDER NO: PERIOD: WORKSHEET
FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET



FROM: __________ S
STATISTICAL DATA AND CERTIFICATION STATEMENT


_______________ TO: ____________ PART I
Intermediary Use Only:








[ ] Audited Date Received ________________
[ ] Initial [ ] Re-opened


[ ] Desk Reviewed Intermediary No. ______________
[ ] Final

PART I - STATISTICAL DATA

[ ] Projected Cost Report
[ ] Actual/Final Cost Report

Check

[ ] Electronic filed cost report
Date:

applicable box

[ ] Manually submitted cost report
Time:

1 Name:




1
1.01 Street:


P.O. Box:
1.01
1.02 City:
State:
Zip Code:
1.02
1.03 County:




1.03
2 Provider Number:




2
3 Designation:




3
4 Reporting Period: From To




4










Type of Control
Type of Provider




(see instructions)
(see instructions) Date Certified

1 2 3 4
5





5










Source of Federal Funds
Grant Award Number



(see instructions)
(see instructions) Date

1 2 3
4
6





6








7 Names of Physicians Furnishing Services At The Health Facility or Under Agreement




7

(As Described in Instructions) and Medicare Billing Numbers (Include all Part B Billing Numbers)







Name


Billing Number


1


2
7.01





7.01
7.02





7.02
7.03





7.03
7.04





7.04
7.05





7.05








8
Supervisory Physicians



8





Hours of Supervision


Name

For Reporting Period


1

2
8.01





8.01
8.02





8.02
8.03





8.03
8.04





8.04
8.05





8.05
















FORM CMS-222-92 (1-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 2903 and 2903.1)














































































































































Rev. 7





29-303









2990 (Cont.)
Form CMS 222-92

12-04
INDEPENDENT RURAL HEALTH CLINIC/


PROVIDER NO: PERIOD: WORKSHEET S
FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET



From: PART I (Cont.) &
STATISTICAL DATA AND CERTIFICATION STATEMENT



To: PART II
PART I (CONTINUED)-STATISTICAL DATA






9 Does the facility operate as other than a RHC or FQHC? Enter "Y" for yes or "N" for no.




9
10 If yes, specify what type of operation. (i.e., physicians office, independent laboratory, etc.)




10
11 Identify days and hours by listing the time the facility operates as a RHC or FQHC next to the applicable day




11


Days

Hours of Operation





From To
11.01
Sunday



11.01
11.02
Monday



11.02
11.03
Tuesday



11.03
11.04
Wednesday



11.04
11.05
Thursday



11.05
11.06
Friday



11.06
11.07
Saturday



11.07
12 Identify days and hours by listing the time the facility operates as other than a RHC or FQHC next to the applicable day.




12


Days

Hours of Operation





From To
12.01
Sunday



12.01
12.02
Monday



12.02
12.03
Tuesday



12.03
12.04
Wednesday



12.04
12.05
Thursday



12.05
12.06
Friday



12.06
12.07
Saturday



12.07
13 If this is a low or no Medicare Utilization cost report, enter "L" for low or "N" for No Medicare Utilization.




13
14 Is this facility filing a consolidated cost report under CMS Pub. 100-4, chapter 9, section




14

30.8? Enter "Y" for yea or "N" for no. If yes, see instructions.





















PART II - CERTIFICATION BY OFFICER OR ADMINISTRATOR














MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY






BE PUNISHABLE BY CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER






FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS REPORT WERE PROVIDED OR PROCURED






THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WHERE OTHERWISE ILLEGAL,






CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT.

















CERTIFICATION BY OFFICER OR ADMINISTRATOR













I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying cost report prepared by






______________________________________ (Provider Name and Number) for the cost report period beginning






________________ and ending ______________ and that to the best of my knowledge and belief, it is a true, correct and






complete statement prepared from the books and records of the Provider in accordance with the laws and regulations regarding






the Provider in accordance with the laws and regulations regarding the provision of health care services and that the services






identified in this cost report were provided in compliance with such laws and regulations.




















(Signed)






Officer or Administrator of Facility


Title
Date








According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a






valid OMB control number. The valid OMB control number for this information collection is 0938-0107. The time required to complete this






information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data






resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the






accuracy of the time estimate(s) or suggestions for improving this form, please write to: Centers for Medicare & Medicaid Services, 7500






Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.














FORM CMS-222-92 (12-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 2903 and 2903.2)






























































29-304





Rev. 7

Sheet 3: WS-S part III^

01-05

Form CMS 222-92

2990 (Cont.)
INDEPENDENT RURAL HEALTH CLINIC/FREESTANDING


PROVIDER NO.: PERIOD: WORKSHEET
FEDERALLY QUALIFIED HEALTH CENTER WORKSHEET


_______________ FROM: __________ S
STATISTICAL DATA AND CERTIFICATION STATEMENT


CLINIC NO.: TO: ____________ PART III




_______________










PART III - STATISTICAL DATA FOR CLINICS FILING UNDER CONSOLIDATED COST REPORTING






1 Name:




1
2 Street:


P.O. Box:
2
3 City:
State:
Zip Code:
3
4 County:




4
5 Provider Number:




5
6 Designation:

Date Certified:
6








7 Names of Physicians Furnishing Services At The Health Facility or Under Agreement




7

(As Described in Instructions) and Medicare Billing Numbers (Include all Part B Billing Numbers)







Name


Billing Number


1


2
7.01





7.01
7.02





7.02
7.03





7.03
7.04





7.04
7.05





7.05








8
Supervisory Physicians



8





Hours of Supervision


Name

For Reporting Period


1

2
8.01





8.01
8.02





8.02
8.03





8.03
8.04





8.04
8.05





8.05








9 Does the facility operate as other than a RHC or FQHC? Enter "Y" for yes or "N" for no.




9
10 If yes, specify what type of operation. (i.e., physicians office, independent laboratory, etc.)




10
11 Identify days and hours by listing the time the facility operates as a RHC or FQHC next to the applicable day




11


Days

Hours of Operation





From To
11.01
Sunday



11.01
11.02
Monday



11.02
11.03
Tuesday



11.03
11.04
Wednesday



11.04
11.05
Thursday



11.05
11.06
Friday



11.06
11.07
Saturday



11.07
12 Identify days and hours by listing the time the facility operates as other than a RHC or FQHC next to the applicable day.




12


Days

Hours of Operation





From To
12.01
Sunday



12.01
12.02
Monday



12.02
12.03
Tuesday



12.03
12.04
Wednesday



12.04
12.05
Thursday



12.05
12.06
Friday



12.06
12.07
Saturday



12.07








FORM CMS-222-92 (1-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTIONS 2903.2)






































Rev. 7





29-304.1
























































































































































































































































































































































































































































































Rev. 7





29-303

Sheet 4: A,p1^

01-05

Form CMS 222-92



2990 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL


Facility No.
Reporting Period
WORKSHEET A

BALANCE OF EXPENSES




From
Page 1







To










Reclassified Adjustments Net


COST CENTER Compen- Other Total Reclassi- Trial Balance Increases Expenses



sation
(Col. 1 + 2) fications (Col. 3 +/- 4) (Decreases) (Col. 5 +/- 6)



1 2 3 4 5 6 7

FACILITY HEALTH CARE STAFF COSTS







1 0100 Physician






1
2 0200 Physician Assistant






2
3 0300 Nurse Practitioner






3
4 0400 Visiting Nurse






4
5 0500 Other Nurse






5
6 0600 Clinical Psychologist






6
7 0700 Clinical Social Worker






7
8 0800 Laboratory Technician






8
9 0900 Other (Specify)






9
10 1000






10
11 1100







11
12
Subtotal-Facility Health Care Staff Costs






12

COSTS UNDER AGREEMENT






13 1300 Physician Services Under Agreement






13
14 1400 Physician Supervision Under Agreement






14
15 1500







15
16
Subtotal Under Agreement (Lines 13-15)






16

OTHER HEALTH CARE COSTS






17 1700 Medical Supplies






17
18 1800 Transportation (Health Care Staff)






18
19 1900 Depreciation-Medical Equipment






19
20 2000 Professional Liability Insurance






20
21 2100 Other (Specify)






21
22 2200






22
23 2300






23
24
Subtotal-Other Health Care Costs (Lines 17-23)






24
25
Total Cost of Services (Other Than






25


Overhead And Other RHC/FQHC Services)








Sum of Lines 12, 16, And 24







FACILITY OVERHEAD-FACILITY COST






26 2600 Rent






26
27 2700 Insurance






27
28 2800 Interest On Mortgage Or Loans






28
29 2900 Utilities






29

































FORM CMS-222-92 (1-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2904)































Rev. 7








29-305

Sheet 5: A,p2^

2990 (Cont.)

Form CMS 222-92



01-05
RECLASSIFICATION AND ADJUSTMENT OF TRIAL


Facility No.
Reporting Period
WORKSHEET A

BALANCE OF EXPENSES




From
Page 2







To










Reclassified Adjustments Net


COST CENTER Compen- Other Total Reclassi- Trial Balance Increases Expenses



sation
(Col. 1 + 2) fications (Col. 3 +/- 4) (Decreases) (Col. 5 +/- 6)



1 2 3 4 5 6 7
30 3000 Depreciation-Buildings And Fixtures






30
31 3100 Depreciation-Equipment






31
32 3200 Housekeeping And Maintenance






32
33 3300 Property Tax






33
34 3400 Other(Specify)






34
35 3500






35
36 3600







36
37
Subtotal-Facility Costs (Lines 26-36)






37

FACILITY OVERHEAD-ADMINISTRATIVE COSTS






38 3800 Office Salaries






38
39 3900 Depreciation-Office Equipment






39
40 4000 Office Supplies






40
41 4100 Legal






41
42 4200 Accounting






42
43 4300 Insurance






43
44 4400 Telephone






44
45 4500 Fringe Benefits And Payroll Taxes






45
46 4600 Other (Specify)






46
47 4700






47
48 4800







48
49
Subtotal-Administrative Cost (Lines 38-48)






49
50
Total Overhead (Lines 37 And 49)






50

COST OTHER THAN RHC/FQHC SERVICES






51 5100 Pharmacy






51
52 5200 Dental






52
53 5300 Optometry






53
54 5400 Other (Specify)






54
55 5500






55
56 5600







56
57
Subtotal-Cost Other Than RHC/FQHC (Lines 51-56)






57

NON-REIMBURSABLE COSTS (Specify)






58 5800






58
59 5900







59
60 6000







60
61
Subtotal Non-Reimbursable Costs (Lines 58-60)






61
62
TOTAL COSTS (Sum Of Lines 25, 50, 57, And 61)






62






















FORM CMS-222-92 (1-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2904)




















29-306








Rev. 7

Sheet 6: A-1

03-02

Form CMS 222-92




2990 (Cont.)
RECLASSIFICATIONS
Facility No.

Reporting Period
WORKSHEET A-1






From







To





CODE INCREASE

DECREASE





COST LINE
COST LINE


EXPLANATION OF ENTRY (1) CENTER NO. AMOUNT (2) CENTER NO. AMOUNT (2)


1 2 3 4 5 6 7
1







1
2







2
3







3
4







4
5







5
6







6
7







7
8







8
9







9
10







10
11







11
12







12
13







13
14







14
15







15
16







16
17







17
18







18
19







19
20







20
21







21
22







22
23







23
24







24
25







25
26







26
27







27
28







28
29







29
30







30
31







31
32







32
33







33
34







34
35







35
36 TOTAL RECLASSIFICATIONS (Sum of Column 4






36

must equal sum of Column 7)







(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.








(2) Transfer to Worksheet A, Col 4, line as appropriate.








FORM CMS-222-92 (3/93) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2905)


















Rev. 5







29-307

Sheet 7: A-2

2990 (Cont.)
Form CMS 222-92

03-02
ADJUSTMENTS TO EXPENSES Facility No.

Reporting Period
WORKSHEET A-2




From






To



Basis for

Expense Classification on Worksheet A



Adjust-

from which amount is to be deducted


Description (1) ment

or to which the amount is to be added



(2)
Amount Cost Center

Line No.

1
2 3

4








1 Investment income on commingled






restricted and unrestricted funds






(chapter 2)






2 Trade, quantity and time discounts






on purchases (chapter 8)
B




3 Rebates and refunds of






expenses (chapter 8)
B




4 Rental of building or office






space to others






5 Home office costs






(chapter 21)






6 Adjustment resulting from transactions From





with related organizations Supp. Wkst.





(chapter 10) A-2-1





7 Vending machines






8 Practitioner Assigned by National






Health Service Corps






9 Depreciation - Buildings and Fixtures



Depreciation
30
10 Depreciation - Equipment



Depreciation
31
11 Other (Specify)






















































































































































12 Total





62
(1) Description - all line references in this column pertain to CMS Pub. PRM 15-I.






(2) Basis for adjustment (SEE INSTRUCTIONS)






A. Costs - if cost, including applicable overhead, can be determined.






B. Amount Received - if cost cannot be determined.














FORM CMS-222-92 (3/93) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS






PUB 15-II, SECTION 2906)














29-308





Rev. 5

Sheet 8: A-2-1

2990 ( Cont. )



Form CMS 222-92





08-04

STATEMENT OF COSTS OF SERVICES


Facility No.


Reporting Period



SUPPLEMENTAL


FROM RELATED ORGANIZATIONS






From



WORKSHEET A-2-1










To



PARTS I-III


Part I. Introduction. Are there any costs included on Worksheet A which resulted from transactions with related organizations as















defined in the Provider Reimbursement Manual, Part I, Chapter 10?















[ ] Yes [ ] No (If "Yes", complete Parts II and III )













Part II. Costs incurred and adjustments required (as result of transactions with related organizations):
























AMOUNT

NET


LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COLUMN 6







ALLOWABLE


ADJUSTMENT












IN COST

(COL.4 MINUS



Line No. Cost Center Expense Items


AMOUNT




COL. 5)



1 2
3

4

5

6


1












1

2












2

3












3

4












4

5 TOTALS (sum of lines 1-4) Transfer col. 6, line 1-4 to Wkst. A,col.6 as appropriate)











5


(Transfer col.6, line 5 to Wkst. A-2, col.2, line 6, Adjustment to Expenses)














Part III. Interrelationship of facility to related organization (s):































The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act, requires the















provider to furnish the information requested on Part III of this worksheet.
































This information is used by the Centers for Medicare & Medicaid Services and its intermediaries in determining that the















costs applicable to services, facilities, and supplies furnished by organizations related to you by common















ownership or control, represent reasonable costs as determined under section 1861 of the Social Security Act.















If the provider does not provide all or any part of the requested information, the cost report is considered















incomplete and not acceptable for purposes of claiming reimbursement under title XVIII.



























































RELATED ORGANIZATION (S)








Percentage



Percentage








SYMBOL
of




of


Type of



(1) Name Ownership

Name
Ownership



Business



1 2 3


4
5


6


1











1

2












2

3












3

4












4



















(1) Use the following symbols to indicate interrelationship to related organizations:
















A. Individual has financial interest (stockholder, partner, etc.) in both related organization and in the provider;















B. Corporation, partnership, or other organization has financial interest in the provider;















C. Provider has financial interest in corporation, partnership, or other organization(s);















D. Director, officer, administrator, or key person of the provider or relative of such person has financial interest















in related organization;















E. Individual is director, officer, administrator, or key person of the provider and related organization;















F. Director, officer, administrator, or key person of related organization or relative of such person has















financial interest in the provider;















G. Other (financial or non-financial) specify _____________________________



















































































































FORM CMS-222-92 (3/93) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, Section 2909)
































29-312












Rev. 6


Sheet 9: B-Part I&II^

01-05 Form CMS 222-92

2990 (Cont.)
VISITS AND OVERHEAD COST FOR Facility No.
Reporting Period
WORKSHEET B
RHC/FQHC SERVICES

From
PARTS I & II



To

PART I - VISITS AND PRODUCTIVITY
Part A - Visits And Productivity



1 2 3 4 5

Number of

Minimum Greater of

FTE Total Productivity Visits Col. 2 or
Positions Personnel Visits Standard (Col. 1 x Col. 3) Col. 4






1. Physicians

4200







2. Physician Assistants

2100







3. Nurse Practitioners

2100







4. Subtotal (Sum of lines 1-3)










5. Visiting Nurse










6. Clinical Psychologist










7. Clinical Social Worker










8. Total Staff




9. Physician Services




Under Agreement




PART II - DETERMINATION OF TOTAL ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES








Amount






10. Cost of RHC/FQHC Services - excluding overhead - (W/S A,Col. 7, Line 25)




11. Cost of Other Than RHC/FQHC Services - Excluding overhead (W/S A, Col. 7, Sum of




Lines 57 and 61)










12. Cost of All Services - excluding overhead - (Sum of Lines 10 and 11)










13. Ratio of RHC/FQHC Services (Line 10 Divided by Line 12)










14. Total Overhead - (W/S A, Col. 7, Line 50)










15. Overhead Applicable to RHC/FQHC Services (Line 13 x Line 14)










16. Total Allowable Cost of RHC/FQHC Services (Sum of Lines 10 and 15)


























































FORM CMS-222-92 (1-2005) INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS




PUB. 15-II SECTIONS 2907 THRU 2907.2)










Rev. 7



29-309

Sheet 10: C-Part 1^

2990 (Cont. )
Form CMS 222-92


01-05
DETERMINATION OF MEDICARE
Facility No. Reporting Period
WORKSHEET C
PAYMENT

From
PART 1



To


PART I- DETERMINATION OF RATE FOR RHC/FQHC SERVICES



AMOUNT
1 Total Allowable Costs(Worksheet B, Part II, Line 16)



1
2 Cost of Pneumococcal and Influenza Vaccine and Its ( Their) Administration



2

(From Supplemental Worksheet B-1, Line 15)




3 Total Allowable Cost Excluding Pneumococcal and Influenza Vaccine



3

(Line 1 - Line 2)




4 Greater of Minimum Visits or Actual Visits by Health Care Staff



4

(Worksheet B, Part 1, Column 5, Line 8




5 Physicians Visits Under Agreements



5

(Worksheet B, Part 1, Column 5, Line 9)




6 Total Adjusted Visits



6

(Line 4 + Line 5)




7 Adjusted Cost Per Visit



7

(Line 3 divided by Line 6)






1 2 2.01 3


Rate Period 1 Rate Period 2 Rate Period 3

8 Maximum Rate Per Visit (See Instructions)



8
9 Rate For Medicare Covered Visits



9

(Lessor of Line 7 or Line 8)

















































































































































































































































































































FORM CMS-222-93 (8-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,





SECTIONS 2908 AND 2908.1)












29-310




Rev. 7

Sheet 11: C-Part II

08-04
Form CMS 222-92


2990 ( Cont. )
DETERMINATION OF MEDICARE
Facility No. Reporting Period
WORKSHEET C
PAYMENT

From
PART II



To


PART II - DETERMINATION OF TOTAL PAYMENT
1 2 2.01 3


Rate period 1 Rate Period 2 Rate Period 3

10 Rate for Medicare Covered Visits (Part I, Line 9)



10
11 Medicare Covered Visits Excluding Mental Health



11

Services (From Intermediary Records)




12 Medicare Cost Excluding Costs for Mental Health



12

Services (Line 10 multiplied by Line 11)




13 Medicare Covered Visits for Mental Health



13

Services (From Intermediary Records)




14 Medicare Covered Cost for Mental Health



14

Services (Line 10 multiplied by Line 13)




15 Limit Adjustment



15

(Line14 multiplied by 62 1/2%) (see instructions)




16 Total Medicare Cost



16

(Line 12 plus line 15)




17 Less: Beneficiary Deductible



17

(From Intermediary Records)




18 Net Medicare Cost Excluding Pneumococcal



18

and Influenza Vaccine and Its (Their) Administration





(Line 16 minus line 17)




19 Reimbursable Cost of RHC/FQHC Services, Other Than Pneumococcal



19

and Influenza Vaccine (80% multiplied by line 18, Column 3)




20 Medicare Cost of Pneumococcal and Influenza Vaccine and



20

Its (Their) Administration (From Supp. Worksheet B-1, Line 16)











21 Total Reimbursable Medicare Cost (Line 19 plus Line 20)



21







22 Less Payments to RHC/FQHC During Reporting Period



22
23 Balance Due To/From The Medicare Program



23

Exclusive of Bad Debts (Line 21 less Line 22)




24 Total Reimbursable Bad Debts, Net of Bad Debt





Recoveries (From Provider Records)



24
24.01 Total Gross Reimbursable Bad Debts for Dual Eligible Beneficiaries



24.01

(From Provider Records)











25 Total Amount Due To/From The Medicare Program (Line 23 plus Line 24)



25


























































































































































FORM CMS-222-93(08/04) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS





PUB 15-II,SECTIONS 2908 AND 2908.2)












Rev. 6



29-311





















Sheet 12: Sup. B-1

08-04
Form CMS 222-92
2990 ( Cont.)
COMPUTATION OF
Facility No. Reporting Period SUPPLEMENTAL
PNEUMOCOCCAL AND INFLUENZA

From WORKSHEET B-1
VACCINE COST

To








PART 1 - CALCULATION OF COST
PNEUMOCOCCAL INFLUENZA
1 Health Care Staff Cost


1

(Worksheet A, Column 7, Line12)



2 Ratio of Pneomococcal and Influenza Vaccine


2

Staff Time to Total Health Care Staff Time



3 Pneumococcal and Influenza Vaccine


3

Health Care Staff Cost (Line 1 x Line 2)



4 Medical Supplies Cost - Pneumococcal and Influenza


4

Vaccine (From Your Records)



5 Direct Cost of Pneumococcal and Influenza


5

Vaccine (Sum of Lines 3 & 4)



6 Total Direct Cost of the Facility


6

(Worksheet A, Column 7, Line 25 )



7 Total Facility Overhead


7

(Worksheet A, Column 7, Line 50)



8 Ratio of Pneumococcal and Influenza Vaccine


8

Direct Cost to Total Direct Cost (Line 5 divided by Line 6)



9 Overhead Cost - Pneumococcal and Influenza


9

Vaccine (Line 7 x Line 8)



10 Total Pneumococcal and Influenza Vaccine Cost and


10

Its (Their) Administration (Sum of Lines 5 & 9)



11 Total Number of Pneumococcal and Influenza


11

Vaccine Injections (From Provider Records)



12 Cost Per Pneumococcal and Influenza


12

Vaccine Injection (Line 10 divided by Line 11)



13 Number of Pneumococcal and Influenza Vaccine


13

Injections Administered to Medicare Beneficiaries



14 Medicare Cost of Pneumococcal and Influenza Vaccine


14

and Its (Their) Administration (Line 12 Multiplied by Line 13)



15 Total Cost of Pneumococcal and Influenza Vaccine and Its (Their)


15

Administration (Sum of Line 10, Columns 1 and 2) Transfer to Wkst. C, Part I, Line 2



16 Total Medicare Cost of Pneumococcal and Influenza Vaccine and Its (Their)


16

Administration (Sum of Line 14, Columns 1 and 2) Transfer to Wkst. C, Part II, Line 20





























































































FORM CMS-222-92(8/04) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB 15-II,




SECTION 2910)










Rev. 6



29-313
File Typeapplication/vnd.ms-excel
Last Modified ByCMS
File Modified2007-12-11
File Created2000-09-14

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