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)

CHAPTER 29

INDEPENDENT RURAL HEALTH CLINIC AND

FREESTANDING FEDERALLY QUALIFIED HEALTH CENTER

COST REPORT

FORM CMS-222-92

Section

General....................................................................................................... 2900

Rounding Standards for Fractional Computations............................ 2900.1

Recommended Sequence For Completing Form CMS-222-92................... 2901

Sequence of Assembly................................................................................ 2902

Sequence of Assembly - Worksheets................................................ 2902.1

Worksheet S - Independent Rural Health Clinic/Federally

Qualified Health Center Statistical Data and

Certification Statement.......................................................................... 2903

Part I - Statistical Data..................................................................... 2903.1

Part II - Certification Statement........................................................ 2903.2

Worksheet A - Reclassification and Adjustment of Trial

Balance of Expenses.............................................................................. 2904

Worksheet A-1 - Reclassification................................................................. 2905

Worksheet A-2 - Adjustments to Expenses.................................................. 2906

Worksheet B - Visits and Overhead Cost For RHCs/FQHCs........................ 2907

Part I - Visits and Productivity......................................................... 2907.1

Part II - Determination of Total Allowable Cost

Applicable To RHC/FQHC Services........................................... 2907.2

Worksheet C - Determination of Medicare Payment..................................... 2908

Part I - Determination of Rate For RHC/FQHC

Services...................................................................................... 2908.1

Part II - Determination of Total Payment......................................... 2908.2

Supplemental Worksheet A-2-1 - Statement of Costs of

Services From Related Organizations..................................................... 2909

Part I - Introduction......................................................................... 2909.1

Part II - Costs Incurred and Adjustments

Required..................................................................................... 2909.2

Part III - Interrelationship of Facility to

Related Organization(s).............................................................. 2909.3

Supplemental Worksheet B-1 - Computation of

Pneumococcal and Influenza Vaccine Cost............................................ 2910

Exhibit 1-Form CMS-222-92 Worksheets.................................................... 2990

E lectronic Cost Reporting Specifications for Form CMS 222-92................ 2995

Rev. 7 29-1