CMS-276 Final Cost Report

Prepaid Health Plan Cost Report

CMS-276.Final Cost Report.xls

Prepaid Health Plan Cost Report (HMO)

OMB: 0938-0165

Document [xlsx]
Download: xlsx | pdf

Overview

Worksheet S
Worksheet D
Worksheet E
Worksheet F
Worksheet G
Worksheet H
Worksheet I
Worksheet J
Worksheet K
Worksheet L
Worksheet M
Worksheet N
Special Administration Costs
Subpart E Limits


Sheet 1: Worksheet S











version 1.1
This report is required by law (42 USC 1395mm and 42 USC 1995I).








FORM APPROVED
Failure to report can result in all interim payments made since








OMB NO. 0938-0165
the beginning of the cost reporting period being deemed overpayments.















































PREPAID HEALTH PLAN COST REPORT







WORKSHEET S

GENERAL INFORMATION





















1 Name and Address of Plan:
















































































2 Reporting Period:






Plan Number:


From:


















H-xxxx


To:



















3 a. Type of Report:
b. Bill Processing Option: c. Reimbursement Under:












[ ] Budget Forecast Budget Forecast
Select Option




1876













[ ] Interim Reports

















[x] Final Cost Report















































































































MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST










REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW




































CERTIFICATION BY OFFICER OF THE PLAN




















I HEREBY CERTIFY that I have examined the accompanying Statement of Reimbursable Cost, the allocation of










expenses and services, and the attached Worksheets for the period from 12/30/1899 to 12/30/1899










and that to the best of my knowledge and belief they are true and correct statements prepared from the books










and records of the Plan in accordance with applicable instructions, except as noted.












































SIGNATURE (Officer or Administrator of the Plan)




DATE




























TITLE




PHONE NUMBER







































FORM CMS 276-08 (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2302)






















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 0938-0165. The time required to complete this information is estimated to average as follows: (1) for HMOs/CMPs,










24 hours to complete the budget forecast, 80 hours to complete the fourth quarter and final cost reports, and 12 hours to complete the first, second, and third quarterly reports;










and (2)for HCPPs, 16 hours to complete the budget forecast, 60 hours to complete the final cost report, and 8 hours to complete the mid-year report. If you have any comments










concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: HCFA, 7500 Security Boulevard, N2-14-26, Baltimore, Maryland










21244-1850 and to the Office of the Information and Regulatory Affairs, Office of Management and Budget, Washington, D.C. 20503.











Sheet 2: Worksheet D


PLAN STATISTICS









WORKSHEET D













PART I


Name of Plan: 0







Page 1


Plan #: H-xxxx















PERIOD FROM:

12/30/99










TO:
12/30/99

























BILLS


TOTAL
MEDICARE
MEDICARE




PROVIDER RELATION- PROCESSED
TOTAL
MEDICARE
PRIMARY
SECONDARY




NUMBER SHIP (1) BY (2)
DAYS
DAYS*
DAYS
DAYS

LIST OF PROVIDERS













1 2 3
4
5
6
7


















A. Hospitals & SNF's:










1
________________________________ ________ _ _
0
0
0
0

2
________________________________ ________ _ _
0
0
0
0

3
________________________________ ________ _ _
0
0
0
0

4
________________________________ ________ _ _
0
0
0
0

5
________________________________ ________ _ _
0
0
0
0

6
________________________________ ________ _ _
0
0
0
0

7
________________________________ ________ _ _
0
0
0
0

8
________________________________ ________ _ _
0
0
0
0

9
________________________________ ________ _ _
0
0
0
0

10
________________________________ ________ _ _
0
0
0
0

11
________________________________ ________ _ _
0
0
0
0

12
________________________________ ________ _ _
0
0
0
0

13
________________________________ ________ _ _
0
0
0
0

14
________________________________ ________ _ _
0
0
0
0

15
________________________________ ________ _ _
0
0
0
0

16
________________________________ ________ _ _
0
0
0
0

17
________________________________ ________ _ _
0
0
0
0

18
________________________________ ________ _ _
0
0
0
0

19
________________________________ ________ _ _
0
0
0
0

20
________________________________ ________ _ _
0
0
0
0

21
________________________________ ________ _ _
0
0
0
0

22
________________________________ ________ _ _
0
0
0
0

23
________________________________ ________ _ _
0
0
0
0

24
________________________________ ________ _ _
0
0
0
0

25
________________________________ ________ _ _
0
0
0
0

26
________________________________ ________ _ _
0
0
0
0

27
________________________________ ________ _ _
0
0
0
0

28
________________________________ ________ _ _
0
0
0
0

29
________________________________ ________ _ _
0
0
0
0

30
________________________________ ________ _ _
0
0
0
0

31
________________________________ ________ _ _
0
0
0
0

32
________________________________ ________ _ _
0
0
0
0

33
________________________________ ________ _ _
0
0
0
0

34
________________________________ ________ _ _
0
0
0
0

35
________________________________ ________ _ _
0
0
0
0

36
________________________________ ________ _ _
0
0
0
0

37
________________________________ ________ _ _
0
0
0
0

38
________________________________ ________ _ _
0
0
0
0

39
________________________________ ________ _ _
0
0
0
0

40
________________________________ ________ _ _
0
0
0
0

41
________________________________ ________ _ _
0
0
0
0

42
________________________________ ________ _ _
0
0
0
0

43
________________________________ ________ _ _
0
0
0
0

44
________________________________ ________ _ _
0
0
0
0

45
________________________________ ________ _ _
0
0
0
0

46
________________________________ ________ _ _
0
0
0
0

47
________________________________ ________ _ _
0
0
0
0

48
________________________________ ________ _ _
0
0
0
0

49
________________________________ ________ _ _
0
0
0
0

50
________________________________ ________ _ _
0
0
0
0

51
________________________________ ________ _ _
0
0
0
0

52
________________________________ ________ _ _
0
0
0
0


























* Note: Col 5 minus 6 & 7 = Non-covered








(1)


(2)










O - OWNED OR CONTROLLED


H - PROCESSED BY HCFA










P - PURCHASED


P - PROCESSED BY PLAN























FORM HCFA 276-99














(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306)































PLAN STATISTICS









WORKSHEET D













PART 1


Name of Plan: 0







Page 2


Plan #: H-xxxx















PERIOD FROM:

12/30/99









TO:
12/30/99


























BILLS


TOTAL
MEDICARE
MEDICARE




PROVIDER RELATION- PROCESSED
TOTAL
MEDICARE
PRIMARY
SECONDARY




NUMBER SHIP (1) BY (2)
VISITS
VISITS*
VISITS
VISITS

LIST OF PROVIDERS













1 2 3
4
5
6
7

















B. HHA's:






1
________________________________ ________ _ _
0
0
0
0

2
________________________________ ________ _ _
0
0
0
0

3
________________________________ ________ _ _
0
0
0
0

4
________________________________ ________ _ _
0
0
0
0

5
________________________________ ________ _ _
0
0
0
0

6
________________________________ ________ _ _
0
0
0
0

7
________________________________ ________ _ _
0
0
0
0

8
________________________________ ________ _ _
0
0
0
0

9
________________________________ ________ _ _
0
0
0
0

10
________________________________ ________ _ _
0
0
0
0

11
________________________________ ________ _ _
0
0
0
0

12
________________________________ ________ _ _
0
0
0
0

13
________________________________ ________ _ _
0
0
0
0

14
________________________________ ________ _ _
0
0
0
0

15
________________________________ ________ _ _
0
0
0
0

16
________________________________ ________ _ _
0
0
0
0

17
________________________________ ________ _ _
0
0
0
0

18
________________________________ ________ _ _
0
0
0
0

19
________________________________ ________ _ _
0
0
0
0

20
________________________________ ________ _ _
0
0
0
0

21
________________________________ ________ _ _
0
0
0
0

22
________________________________ ________ _ _
0
0
0
0

23
________________________________ ________ _ _
0
0
0
0

24
________________________________ ________ _ _
0
0
0
0

25
________________________________ ________ _ _
0
0
0
0

C. Other (Specify Name & Type):








1
________________________________ ________ _ _
0
0
0
0

2
________________________________ ________ _ _
0
0
0
0

3
________________________________ ________ _ _
0
0
0
0

4
________________________________ ________ _ _
0
0
0
0

5
________________________________ ________ _ _
0
0
0
0

6
________________________________ ________ _ _
0
0
0
0

7
________________________________ ________ _ _
0
0
0
0

8
________________________________ ________ _ _
0
0
0
0

9
________________________________ ________ _ _
0
0
0
0

10
________________________________ ________ _ _
0
0
0
0

11
________________________________ ________ _ _
0
0
0
0

12
________________________________ ________ _ _
0
0
0
0

13
________________________________ ________ _ _
0
0
0
0

14
________________________________ ________ _ _
0
0
0
0

15
________________________________ ________ _ _
0
0
0
0

16
________________________________ ________ _ _
0
0
0
0

17
________________________________ ________ _ _
0
0
0
0

18
________________________________ ________ _ _
0
0
0
0

19
________________________________ ________ _ _
0
0
0
0

20
________________________________ ________ _ _
0
0
0
0

21
________________________________ ________ _ _
0
0
0
0

22
________________________________ ________ _ _
0
0
0
0

23
________________________________ ________ _ _
0
0
0
0

24
________________________________ ________ _ _
0
0
0
0

25
________________________________ ________ _ _
0
0
0
0


























* Note: Col 5 minus 6 & 7 = Non-covered








(1)


(2)










O - OWNED OR CONTROLLED


H - PROCESSED BY HCFA










P - PURCHASED


P - PROCESSED BY PLAN























FORM HCFA 276-99














(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306)














































PLAN STATISTICS









WORKSHEET D












PART II


Name of Plan: 0







Page 1


Plan #: H-xxxx















PERIOD FROM:

12/30/99










TO:
12/30/99


























HOW



STATISTICS





TYPE OF PAYMENT PHYSICIANS


TOTAL
MEDICARE
MEDICARE




GROUP MECHANISM PAID
TOTAL
MEDICARE *
PRIMARY
SECONDARY

LIST OF SUPPLIERS

(1) (2) (2)








1 2 3
4
5
6
7

















A. Physician Services:








1
________________________________ _ _ _
0
0
0
0

2
________________________________ _ _ _
0
0
0
0

3
________________________________ _ _ _
0
0
0
0

4
________________________________ _ _ _
0
0
0
0

5
________________________________ _ _ _
0
0
0
0

6
________________________________ _ _ _
0
0
0
0

7
________________________________ _ _ _
0
0
0
0

8
________________________________ _ _ _
0
0
0
0

9
________________________________ _ _ _
0
0
0
0

10
________________________________ _ _ _
0
0
0
0

11
________________________________ _ _ _
0
0
0
0

12
________________________________ _ _ _
0
0
0
0

13
________________________________ _ _ _
0
0
0
0

14
________________________________ _ _ _
0
0
0
0

15
________________________________ _ _ _
0
0
0
0

16
________________________________ _ _ _
0
0
0
0

17
________________________________ _ _ _
0
0
0
0

18
________________________________ _ _ _
0
0
0
0

19
________________________________ _ _ _
0
0
0
0

20
________________________________ _ _ _
0
0
0
0

21
________________________________ _ _ _
0
0
0
0

22
________________________________ _ _ _
0
0
0
0

23
________________________________ _ _ _
0
0
0
0

24
________________________________ _ _ _
0
0
0
0

25
________________________________ _ _ _
0
0
0
0

26
________________________________ _ _ _
0
0
0
0

27
________________________________ _ _ _
0
0
0
0

28
________________________________ _ _ _
0
0
0
0

29
________________________________ _ _ _
0
0
0
0

30
________________________________ _ _ _
0
0
0
0

31
________________________________ _ _ _
0
0
0
0

32
________________________________ _ _ _
0
0
0
0

33
________________________________ _ _ _
0
0
0
0

34
________________________________ _ _ _
0
0
0
0

35
________________________________ _ _ _
0
0
0
0

36
________________________________ _ _ _
0
0
0
0

37
________________________________ _ _ _
0
0
0
0

38
________________________________ _ _ _
0
0
0
0

39
________________________________ _ _ _
0
0
0
0

40
________________________________ _ _ _
0
0
0
0

41
________________________________ _ _ _
0
0
0
0

42
________________________________ _ _ _
0
0
0
0

43
________________________________ _ _ _
0
0
0
0

44
________________________________ _ _ _
0
0
0
0

45
________________________________ _ _ _
0
0
0
0

46
________________________________ _ _ _
0
0
0
0

47
________________________________ _ _ _
0
0
0
0

48
________________________________ _ _ _
0
0
0
0


































(1)


(2)









A - IPA


A - FEE-FOR-SERVICE









B - GROUP PRACTICE


B - CAPITATION









C - STAFF


C - OTHER-SPECIFY









D - INDIVIDUAL PRACTITIONERS

















* Note Col 5 minus 6 & 7 = Non-covered



































FORM HCFA 276-99












(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 2306)





























PLAN STATISTICS









WORKSHEET D













PART II



Name of Plan: 0







Page 2



Plan #: H-xxxx
















PERIOD FROM:

12/30/99











TO:
12/30/99


























HOW

STATISTICS








TYPE OF PAYMENT PHYSICIANS


TOTAL
MEDICARE
MEDICARE




GROUP MECHANISM PAID
TOTAL
MEDICARE*
PRIMARY
SECONDARY

LIST OF SUPPLIERS

(1) (2) (2)








1 2 3
4
5
6
7

















B. Certified Labs:






1
________________________________ _ _ _
0
0
0
0

2
________________________________ _ _ _
0
0
0
0

3
________________________________ _ _ _
0
0
0
0

4
________________________________ _ _ _
0
0
0
0

5
________________________________ _ _ _
0
0
0
0

6
________________________________ _ _ _
0
0
0
0

7
________________________________ _ _ _
0
0
0
0

8
________________________________ _ _ _
0
0
0
0

9
________________________________ _ _ _
0
0
0
0








C. X-Ray Units:






1
____________________________________________ _ _ _
0
0
0
0

2
____________________________________________ _ _ _
0
0
0
0

3
____________________________________________ _ _ _
0
0
0
0

4
____________________________________________ _ _ _
0
0
0
0

5
____________________________________________ _ _ _
0
0
0
0

6
____________________________________________ _ _ _
0
0
0
0

7
____________________________________________ _ _ _
0
0
0
0

8
____________________________________________ _ _ _
0
0
0
0

9
____________________________________________ _ _ _
0
0
0
0








D. Others (Specify):









1
____________________________________________ _ _ _
0
0
0
0

2
____________________________________________ _ _ _
0
0
0
0

3
____________________________________________ _ _ _
0
0
0
0

4
____________________________________________ _ _ _
0
0
0
0

5
____________________________________________ _ _ _
0
0
0
0

6
____________________________________________ _ _ _
0
0
0
0

7
____________________________________________ _ _ _
0
0
0
0

8
____________________________________________ _ _ _
0
0
0
0

9
____________________________________________ _ _ _
0
0
0
0

10
____________________________________________ _ _ _
0
0
0
0

11
____________________________________________ _ _ _
0
0
0
0

12
____________________________________________ _ _ _
0
0
0
0

13
____________________________________________ _ _ _
0
0
0
0

14
________________________________ _ _ _
0
0
0
0


























* Note: Col 5 minus 6 & 7 = Non-covered





(1)
(1)


(2)








A - IPA
A - IPA


A - FEE-FOR-SERVICE








B - GROUP PRACTICE
B - GROUP PRACTICE


B - CAPITATION








C - STAFF
C - STAFF


C - OTHER-SPECIFY








D - INDIVIDUAL PRACTITIONERS
D - INDIVIDUAL PRACTITIONERS







































MEDICARE
MEDICARE


E. MEMBERSHIP:








PART A
PART B












1
2

1 Total Medicare Member Months....................................................................................................................................................................................……………….












2 Medicare Secondary Liable (Employer Groups) Member Months................................................................................................................................................................................























__________
__________

3 Medicare Primary Member Months (Line 1 minus Line 2).......................................................................................................................................................................................................







0
0

4 Ratio (Line 3 & Line 1)....................................................................................................................................................................................................................................







0.0000
0.0000

























































(3)














Part B Member Months = Total Member Months





































FORM CMS 276-08














(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2306)














Sheet 3: Worksheet E


SUMMARY TRIAL BALANCE





WORKSHEET E

















Name of Plan:
0







Plan #:
H-xxxx












PERIOD FROM: 12/30/99










TO: 12/30/99























A & G
TRANSFER




TRIAL RECLASSIFI- ADJUSTMENTS ALLOWABLE ALLOCATION TOTALS
TO


COST CENTER
BALANCE CATIONS
COST (WKST I,
WKST, LINE






(WKST F) (WKST G) (Col 1 thru 3) Part I) (Col 4 + Col 5)






1 2 3 4 5 6
7














1 Inpatient Hospitals ……………….


0 0 0 0 0
J 2-47

2 Outpatient Hospitals …………….


0 0 0 0 0
J 2-47

3 Skilled Nursing Facilities.......….…


0 0 0 0 0
J 52-61

4 Home Health Agencies........….….

0 0 0 0 0
J 66-74

5 Clinics..........……….........….......…


0 0 0 0 0
K | 1

6 Physician Groups.......................…


0 0 0 0 0
K | 2-6

7 Individual Physicians.....…...….…


0 0 0 0 0
K | 7

8 Certified Labs..................…......…


0 0 0 0 0
K | 8-10

9 X-Ray Units....................……....…


0 0 0 0 0
K | 11-13

10 ESRD Facilities.........................…


0 0 0 0 0
K | 14-15

11 Durable Medical Equipment.......…


0 0 0 0 0
K | 16

12 Ambulance...............……….......…


0 0 0 0 0
K | 17

13 Pharmacy (Outpatient).......…...…


0 0 0 0 0



13a Pharmacy-Medicare Covered Rx


0 0 0 0 0



14 Emergency-Urgent Needed Svcs..


0 0 0 0 0
K | 18

15 Mental Health Services....….……


0 0 0 0 0
K | 19&20

16 DED+CO pd by MAC/Carrier/Inter


0 0 0 0 0
L | 18

17 Other - Medicare Bad Debts...…


0 0 0 0 0
L | 9

18 Other - Blood Deductible.....…


0 0 0 0 0
L | 12

19 Other - (Specify)...…….......…


0 0 0 0 0
J&K |

20 Other - (Specify)...…….......…


0 0 0 0 0
J&K |

21 Other - (Specify)...…….......…


0 0 0 0 0
J&K |

22 Other - (Specify)...…….......…


0 0 0 0 0
J&K |

23 Other - (Specify)...…….......…


0 0 0 0 0
J&K |




_____________
_____________ _____________ _____________ _____________ ___________



24 Subtotal (Sum Lines 1-23).................................................................................................
0
0 0 0 0 0
















25 Plan Administration..............…..…


0 0 0 0 0
L | 3

26 Special Admin Costs................…


0 0 0 0 0
L | 6




_____________
_____________ _____________ _____________ _____________ ___________



27 Subtotal: (Sum Lns 25+26)...................................................................................................................................
0
0 0 0 0 0
















28 Admin & General Costs...…......…


0 0 0 0 0




_____________
_____________ _____________ _____________ _____________ ___________

















29 Total Program Costs (24+27+28)......................................................................................................................
0
0 0 0 0 0






========= ========= ========= ========= ========= =========

















FORM CMS 276-08









(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2307)





















Sheet 4: Worksheet F


RECLASSIFICATIONS





WORKSHEET F

Name of Plan: 0




Page 1

Plan #: H-xxxx
PERIOD FROM:
12/30/99






TO:
12/30/99

















CC LINE

AMOUNT (2)




CODE COST CENTER NUMBER





LINE EXPLANATION OF RECLASSIFICATION ENTRY (1) (Worksheet E) (WKST E)
INCREASES
(DECREASES)


1 2 3
4
5












1 ____________________________________________ ______ _________________________ ___________
0
0

2 ____________________________________________ ______ _________________________ ___________
0
0

3 ____________________________________________ ______ _________________________ ___________
0
0

4 ____________________________________________ ______ _________________________ ___________
0
0

5 ____________________________________________ ______ _________________________ ___________
0
0

6 ____________________________________________ ______ _________________________ ___________
0
0

7 ____________________________________________ ______ _________________________ ___________
0
0

8 ____________________________________________ ______ _________________________ ___________
0
0

9 ____________________________________________ ______ _________________________ ___________
0
0

10 ____________________________________________ ______ _________________________ ___________
0
0

11 ____________________________________________ ______ _________________________ ___________
0
0

12 ____________________________________________ ______ _________________________ ___________
0
0

13 ____________________________________________ ______ _________________________ ___________
0
0

14 ____________________________________________ ______ _________________________ ___________
0
0

15 ____________________________________________ ______ _________________________ ___________
0
0

16 ____________________________________________ ______ _________________________ ___________
0
0

17 ____________________________________________ ______ _________________________ ___________
0
0

18 ____________________________________________ ______ _________________________ ___________
0
0

19 ____________________________________________ ______ _________________________ ___________
0
0

20 ____________________________________________ ______ _________________________ ___________
0
0

21 ____________________________________________ ______ _________________________ ___________
0
0

22 ____________________________________________ ______ _________________________ ___________
0
0

23 ____________________________________________ ______ _________________________ ___________
0
0

24 ____________________________________________ ______ _________________________ ___________
0
0

25 ____________________________________________ ______ _________________________ ___________
0
0

26 ____________________________________________ ______ _________________________ ___________
0
0

27 ____________________________________________ ______ _________________________ ___________
0
0

28 ____________________________________________ ______ _________________________ ___________
0
0

29 ____________________________________________ ______ _________________________ ___________
0
0

30 ____________________________________________ ______ _________________________ ___________
0
0

31 ____________________________________________ ______ _________________________ ___________
0
0

32 ____________________________________________ ______ _________________________ ___________
0
0

33 ____________________________________________ ______ _________________________ ___________
0
0

34 ____________________________________________ ______ _________________________ ___________
0
0

35 ____________________________________________ ______ _________________________ ___________
0
0

36 ____________________________________________ ______ _________________________ ___________
0
0

37 ____________________________________________ ______ _________________________ ___________
0
0

38 ____________________________________________ ______ _________________________ ___________
0
0

39 ____________________________________________ ______ _________________________ ___________
0
0

40 ____________________________________________ ______ _________________________ ___________
0
0

41 ____________________________________________ ______ _________________________ ___________
0
0

42 ____________________________________________ ______ _________________________ ___________
0
0

43 ____________________________________________ ______ _________________________ ___________
0
0

44 ____________________________________________ ______ _________________________ ___________
0
0

45 ____________________________________________ ______ _________________________ ___________
0
0

46 ____________________________________________ ______ _________________________ ___________
0
0

47 ____________________________________________ ______ _________________________ ___________
0
0

48 ____________________________________________ ______ _________________________ ___________
0
0

49 ____________________________________________ ______ _________________________ ___________
0
0

50 ____________________________________________ ______ _________________________ ___________
0
0







___________
___________

51 Page total...................................................................................................................... . . .
0
0

52 a. Subtotal from Page 2................................................................................................................. . . .
0
0


b. Subtotal from Page 3................................................................................................................. . . .
0
0


c. Subtotal from Page 4................................................................................................................. . . .
0
0

53 Total Reclassifications (Col 4 must equal Col 5)...................................................................................................... . . .
0
0






============
============


(1) A Letter (A, B, etc.) Must Be Entered on Each Line to Identify Each Reclassification Entry.



Net, must be 0
0


(2) Transfer to Worksheet E, Col. 2, lines as appropriate.





============







Summarized on Worksheet F, Page 3













FORM CMS 276-08









(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)





























RECLASSIFICATIONS






WORKSHEET F

Name of Plan: 0




Page 2

Plan #: H-xxxx
PERIOD FROM:
12/30/99






TO:
12/30/99




























CC LINE

AMOUNT




CODE COST CENTER NUMBER





LINE EXPLANATION OF RECLASSIFICATION ENTRY (1) (Worksheet E) (WKST E)
INCREASES
(DECREASES)


1 2 3
4
5

54 ____________________________________________ ______ _________________________ ___________
0
0

55 ____________________________________________ ______ _________________________ ___________
0
0

56 ____________________________________________ ______ _________________________ ___________
0
0

57 ____________________________________________ ______ _________________________ ___________
0
0

58 ____________________________________________ ______ _________________________ ___________
0
0

59 ____________________________________________ ______ _________________________ ___________
0
0

60 ____________________________________________ ______ _________________________ ___________
0
0

61 ____________________________________________ ______ _________________________ ___________
0
0

62 ____________________________________________ ______ _________________________ ___________
0
0

63 ____________________________________________ ______ _________________________ ___________
0
0

64 ____________________________________________ ______ _________________________ ___________
0
0

65 ____________________________________________ ______ _________________________ ___________
0
0

66 ____________________________________________ ______ _________________________ ___________
0
0

67 ____________________________________________ ______ _________________________ ___________
0
0

68 ____________________________________________ ______ _________________________ ___________
0
0

69 ____________________________________________ ______ _________________________ ___________
0
0

70 ____________________________________________ ______ _________________________ ___________
0
0

71 ____________________________________________ ______ _________________________ ___________
0
0

72 ____________________________________________ ______ _________________________ ___________
0
0

73 ____________________________________________ ______ _________________________ ___________
0
0

74 ____________________________________________ ______ _________________________ ___________
0
0

75 ____________________________________________ ______ _________________________ ___________
0
0

76 ____________________________________________ ______ _________________________ ___________
0
0

77 ____________________________________________ ______ _________________________ ___________
0
0

78 ____________________________________________ ______ _________________________ ___________
0
0

79 ____________________________________________ ______ _________________________ ___________
0
0

80 ____________________________________________ ______ _________________________ ___________
0
0

81 ____________________________________________ ______ _________________________ ___________
0
0

82 ____________________________________________ ______ _________________________ ___________
0
0

83 ____________________________________________ ______ _________________________ ___________
0
0

84 ____________________________________________ ______ _________________________ ___________
0
0

85 ____________________________________________ ______ _________________________ ___________
0
0

86 ____________________________________________ ______ _________________________ ___________
0
0

87 ____________________________________________ ______ _________________________ ___________
0
0

88 ____________________________________________ ______ _________________________ ___________
0
0

89 ____________________________________________ ______ _________________________ ___________
0
0

90 ____________________________________________ ______ _________________________ ___________
0
0

91 ____________________________________________ ______ _________________________ ___________
0
0

92 ____________________________________________ ______ _________________________ ___________
0
0

93 ____________________________________________ ______ _________________________ ___________
0
0

94 ____________________________________________ ______ _________________________ ___________
0
0

95 ____________________________________________ ______ _________________________ ___________
0
0

96 ____________________________________________ ______ _________________________ ___________
0
0

97 ____________________________________________ ______ _________________________ ___________
0
0

98 ____________________________________________ ______ _________________________ ___________
0
0

99 ____________________________________________ ______ _________________________ ___________
0
0

100 ____________________________________________ ______ _________________________ ___________
0
0

101 ____________________________________________ ______ _________________________ ___________
0
0

102 ____________________________________________ ______ _________________________ ___________
0
0

103 ____________________________________________ ______ _________________________ ___________
0
0

104 ____________________________________________ ______ _________________________ ___________
0
0

105 ____________________________________________ ______ _________________________ ___________
0
0

106 ____________________________________________ ______ _________________________ ___________
0
0

107 ____________________________________________ ______ _________________________ ___________
0
0

108 ____________________________________________ ______ _________________________ ___________
0
0

109 ____________________________________________ ______ _________________________ ___________
0
0






___________
___________

110 Total Page 2 (Col 4 must equal Col 5).............................................................. . . .
0
0






============
============


(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.



Summarized on Worksheet F, Page 3


(2) Transfer to Worksheet E, Col. 2, lines as appropriate.




















FORM CMS 276-08









(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)


















RECLASSIFICATIONS






WORKSHEET F

Name of Plan: 0




Page 3

Plan #: H-xxxx
PERIOD FROM:
12/30/99






TO:
12/30/99




























CC LINE

AMOUNT




CODE COST CENTER NUMBER





LINE EXPLANATION OF RECLASSIFICATION ENTRY (1) (Worksheet E) (WKST E)
INCREASES
(DECREASES)


1 2 3
4
5

111 ____________________________________________ ______ _________________________ ___________
0
0

112 ____________________________________________ ______ _________________________ ___________
0
0

113 ____________________________________________ ______ _________________________ ___________
0
0

114 ____________________________________________ ______ _________________________ ___________
0
0

115 ____________________________________________ ______ _________________________ ___________
0
0

116 ____________________________________________ ______ _________________________ ___________
0
0

117 ____________________________________________ ______ _________________________ ___________
0
0

118 ____________________________________________ ______ _________________________ ___________
0
0

119 ____________________________________________ ______ _________________________ ___________
0
0

120 ____________________________________________ ______ _________________________ ___________
0
0

121 ____________________________________________ ______ _________________________ ___________
0
0

122 ____________________________________________ ______ _________________________ ___________
0
0

123 ____________________________________________ ______ _________________________ ___________
0
0

124 ____________________________________________ ______ _________________________ ___________
0
0

125 ____________________________________________ ______ _________________________ ___________
0
0

126 ____________________________________________ ______ _________________________ ___________
0
0

127 ____________________________________________ ______ _________________________ ___________
0
0

128 ____________________________________________ ______ _________________________ ___________
0
0

129 ____________________________________________ ______ _________________________ ___________
0
0

130 ____________________________________________ ______ _________________________ ___________
0
0

131 ____________________________________________ ______ _________________________ ___________
0
0

132 ____________________________________________ ______ _________________________ ___________
0
0

133 ____________________________________________ ______ _________________________ ___________
0
0

134 ____________________________________________ ______ _________________________ ___________
0
0

135 ____________________________________________ ______ _________________________ ___________
0
0

136 ____________________________________________ ______ _________________________ ___________
0
0

137 ____________________________________________ ______ _________________________ ___________
0
0

138 ____________________________________________ ______ _________________________ ___________
0
0

139 ____________________________________________ ______ _________________________ ___________
0
0

140 ____________________________________________ ______ _________________________ ___________
0
0

141 ____________________________________________ ______ _________________________ ___________
0
0

142 ____________________________________________ ______ _________________________ ___________
0
0

143 ____________________________________________ ______ _________________________ ___________
0
0

144 ____________________________________________ ______ _________________________ ___________
0
0

145 ____________________________________________ ______ _________________________ ___________
0
0

146 ____________________________________________ ______ _________________________ ___________
0
0

147 ____________________________________________ ______ _________________________ ___________
0
0

148 ____________________________________________ ______ _________________________ ___________
0
0

149 ____________________________________________ ______ _________________________ ___________
0
0

150 ____________________________________________ ______ _________________________ ___________
0
0

151 ____________________________________________ ______ _________________________ ___________
0
0

152 ____________________________________________ ______ _________________________ ___________
0
0

153 ____________________________________________ ______ _________________________ ___________
0
0

154 ____________________________________________ ______ _________________________ ___________
0
0

155 ____________________________________________ ______ _________________________ ___________
0
0

156 ____________________________________________ ______ _________________________ ___________
0
0

157 ____________________________________________ ______ _________________________ ___________
0
0

158 ____________________________________________ ______ _________________________ ___________
0
0

159 ____________________________________________ ______ _________________________ ___________
0
0

160 ____________________________________________ ______ _________________________ ___________
0
0

161 ____________________________________________ ______ _________________________ ___________
0
0

162 ____________________________________________ ______ _________________________ ___________
0
0

163 ____________________________________________ ______ _________________________ ___________
0
0

164 ____________________________________________ ______ _________________________ ___________
0
0

165 ____________________________________________ ______ _________________________ ___________
0
0

166 ____________________________________________ ______ _________________________ ___________
0
0






___________
___________

167 Total Page 3 (Col 4 must equal Col 5).............................................................. . . .
0
0






============
============


(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.



Summarized on Worksheet F, Page 3


(2) Transfer to Worksheet E, Col. 2, lines as appropriate.




















FORM CMS 276-08









(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)


















RECLASSIFICATIONS






WORKSHEET F

Name of Plan: 0




Page 4

Plan #: H-xxxx
PERIOD FROM:
12/30/99






TO:
12/30/99




























CC LINE

AMOUNT




CODE COST CENTER NUMBER





LINE EXPLANATION OF RECLASSIFICATION ENTRY (1) (Worksheet E) (WKST E)
INCREASES
(DECREASES)


1 2 3
4
5

168 ____________________________________________ ______ _________________________ ___________
0
0

169 ____________________________________________ ______ _________________________ ___________
0
0

170 ____________________________________________ ______ _________________________ ___________
0
0

171 ____________________________________________ ______ _________________________ ___________
0
0

172 ____________________________________________ ______ _________________________ ___________
0
0

173 ____________________________________________ ______ _________________________ ___________
0
0

174 ____________________________________________ ______ _________________________ ___________
0
0

175 ____________________________________________ ______ _________________________ ___________
0
0

176 ____________________________________________ ______ _________________________ ___________
0
0

177 ____________________________________________ ______ _________________________ ___________
0
0

178 ____________________________________________ ______ _________________________ ___________
0
0

179 ____________________________________________ ______ _________________________ ___________
0
0

180 ____________________________________________ ______ _________________________ ___________
0
0

181 ____________________________________________ ______ _________________________ ___________
0
0

182 ____________________________________________ ______ _________________________ ___________
0
0

183 ____________________________________________ ______ _________________________ ___________
0
0

184 ____________________________________________ ______ _________________________ ___________
0
0

185 ____________________________________________ ______ _________________________ ___________
0
0

186 ____________________________________________ ______ _________________________ ___________
0
0

187 ____________________________________________ ______ _________________________ ___________
0
0

188 ____________________________________________ ______ _________________________ ___________
0
0

189 ____________________________________________ ______ _________________________ ___________
0
0

190 ____________________________________________ ______ _________________________ ___________
0
0

191 ____________________________________________ ______ _________________________ ___________
0
0

192 ____________________________________________ ______ _________________________ ___________
0
0

193 ____________________________________________ ______ _________________________ ___________
0
0

194 ____________________________________________ ______ _________________________ ___________
0
0

195 ____________________________________________ ______ _________________________ ___________
0
0

196 ____________________________________________ ______ _________________________ ___________
0
0

197 ____________________________________________ ______ _________________________ ___________
0
0

198 ____________________________________________ ______ _________________________ ___________
0
0

199 ____________________________________________ ______ _________________________ ___________
0
0

200 ____________________________________________ ______ _________________________ ___________
0
0

201 ____________________________________________ ______ _________________________ ___________
0
0

202 ____________________________________________ ______ _________________________ ___________
0
0

203 ____________________________________________ ______ _________________________ ___________
0
0

204 ____________________________________________ ______ _________________________ ___________
0
0

205 ____________________________________________ ______ _________________________ ___________
0
0

206 ____________________________________________ ______ _________________________ ___________
0
0

207 ____________________________________________ ______ _________________________ ___________
0
0

208 ____________________________________________ ______ _________________________ ___________
0
0

209 ____________________________________________ ______ _________________________ ___________
0
0

210 ____________________________________________ ______ _________________________ ___________
0
0

211 ____________________________________________ ______ _________________________ ___________
0
0

212 ____________________________________________ ______ _________________________ ___________
0
0

213 ____________________________________________ ______ _________________________ ___________
0
0

214 ____________________________________________ ______ _________________________ ___________
0
0

215 ____________________________________________ ______ _________________________ ___________
0
0

216 ____________________________________________ ______ _________________________ ___________
0
0

217 ____________________________________________ ______ _________________________ ___________
0
0

218 ____________________________________________ ______ _________________________ ___________
0
0

219 ____________________________________________ ______ _________________________ ___________
0
0

220 ____________________________________________ ______ _________________________ ___________
0
0

221 ____________________________________________ ______ _________________________ ___________
0
0

222 ____________________________________________ ______ _________________________ ___________
0
0

223 ____________________________________________ ______ _________________________ ___________
0
0






___________
___________

224 Total Page 4 (Col 4 must equal Col 5).............................................................. . . .
0
0






============
============


(1) A Letter (A,B, etc.) Must be Entered on Each Line to Identify Each Reclassification Entry.



Summarized on Worksheet F, Page 3


(2) Transfer to Worksheet E, Col. 2, lines as appropriate.




















FORM CMS 276-08









(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)



















SUMMARY OF RECLASSIFICATIONS





WORKSHEET F

Name of Plan: 0




Page 5

Plan #: H-xxxx
PERIOD FROM:
12/30/99






TO:
12/30/99
























SUMMARY OF RECLASSIFICATIONS
















INCREASES
(DECREASES)
NET

CC
(From Worksheet F, Pgs 1 & 2)



LINE COST CENTER DESCRIPTIONS 4
5
6












1 Inpatient Hospitals ……………………………………………………………….. ……………….. . 0
0
0

2 Outpatient Hospitals …………………………………………………………… ………………… . 0
0
0

3 Skilled Nursing Facilities............................................................................................................................. . . 0
0
0

4 Home Health Agencies.......................................................................................................................................... . . 0
0
0

5 Clinics.......................................................................................................................................................... . . 0
0
0

6 Physician Groups................................................................................................................................................ . . 0
0
0

7 Individual Physicians........................................................................................................................................... . . 0
0
0

8 Certified Labs.................................................................................................................................................. . . 0
0
0

9 X-Ray Units................................................................................................................................................. . . 0
0
0

10 ESRD Facilities........................................................................................................................ . . 0
0
0

11 Durable Medical Equipment.............................................................................................................. . . 0
0
0

12 Ambulances................................................................................................................................ . . 0
0
0

13 Pharmacy (Outpatient).......................................................................................................................................... . . 0
0
0

13a Pharmacy-Medicare Covered Rx............................................................................................................................... . . 0
0
0

14 Emergency-Urgently Needed Svcs................................................................................................. . . 0
0
0

15 Mental Health Services........................................................................................................................................... . . 0
0
0

16 DED+CO pd by the MAC/Carriers/Intermediaries........................................................................................................... . . 0
0
0

17 Other - Medicare Bad Debts...… . . 0
0
0

18 Other - Blood Deductible.....… . . 0
0
0

19 Other - (Specify)...…….......… . . 0
0
0

20 Other - (Specify)...…….......… . . 0
0
0

21 Other - (Specify)...…….......… . . 0
0
0

22 Other - (Specify)...…….......… . . 0
0
0

23 Other - (Specify)...…….......… . . 0
0
0

24









25 Plan Administration.................................................................................................. . . 0
0
0

26 Special Admin Costs.................................................................................... . . 0
0
0

27









28 Admin & General Costs............................................................................. . . 0
0
0




____________
____________
____________

29 Total Reclassifications (Lines 1 thru 28) (Col 6 must net to zero)......................................
. 0
0
0




=============
=============
=============












DIFFERENCES from total of pages 1 & 2 on page 1, Line 53……………………………………………………………………………..

0
0







=============
=============
Must net to zero.




















To Worksheet E




If these differences are not
Column 2





zero there is a problem!!


















FORM CMS 276-08




(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2308)































SUPPLEMENT TO WORKSHEET F - RECLASSIFICATIONS









Name of Plan: 0








Plan #: H-xxxx Period From:
12/30/99







To:
12/30/99
AD181...AN240
























THIS IS A SUPPLEMENTAL WORKSHEET TO SUM UP RECLASSIFICATIONS BY COST CENTER



















CCNO


INCREASES
(DECREASES)



1 IP Hosp

Err:504
0



CCNO









2 OP Hosp

Err:504
0



CCNO









3 SNF

Err:504
0



CCNO









4 HHA

Err:504
0



CCNO









5 Clinic

Err:504
0



CCNO









6 Physicians Groups

Err:504
0



CCNO









7 Ind Phy

Err:504
0



CCNO









8 Labs

Err:504
0



CCNO









9 Xray

Err:504
0



CCNO









10 ESRD

Err:504
0



CCNO









11 DME

Err:504
0



CCNO









12 Amb

Err:504
0



CCNO









13 Phrm

Err:504
0



CCNO









14 Emerg

Err:504
0



CCNO









15 Mental

Err:504
0



CCNO









16 Ded & Coins

Err:504
0



CCNO









17


Err:504
0



CCNO









18 Other

Err:504
0



CCNO









19 Nonallowable

Err:504
0



CCNO









21 Plan Admin

Err:504
0



CCNO









22 Spec Admin

Err:504
0



CCNO









24 A&G

Err:504
0






------------
------------






Err:504
0






=============
=============












Sheet 5: Worksheet G



ADJUSTMENTS TO EXPENSES



WORKSHEET G



Name of Plan: 0


PART I



Plan #: H-xxxx PERIOD FROM: 12/30/99
Page 1





TO: 12/30/99
















BASIS Amount (2) CC LINE

CC

FOR (To Wkst E as COST CENTER NUMBER

LINE DESCRIPTIONS
ADJ (1) appropriate) (Wkst E) (Wkst E)




1 2 3 4











1 Investment income on commingled restricted & unrestricted funds.......................................................
_ 0
_____________________________ __

2 Trade, quantity, time & other discounts on purchases.......................................................
_ 0
_____________________________ __

3 Rebates & refunds of expenses......................................................................................................
_ 0
_____________________________ __

4 Rental of space by suppliers.................................................................................................
_ 0
_____________________________ __

5 Telephone service.....................................................................................................................
_ 0
_____________________________ __

6 Television & radio service....................................................................................................
_ 0
_____________________________ __

7 Parking lot...................................................................................................................................
_ 0
_____________________________ __

8 Home Office Costs (Attach copy of Home Office Cost Statemenmt)..........
_ 0
_____________________________ __

9 Sale of scrap, waste, etc......................................................................................................
_ 0
_____________________________ __

10 Adj. resulting from transactions with related organizations (3).....................................
_ 0
_____________________________ __

10a Adj. resulting from transactions with related organizations (3).....................................
_ 0
_____________________________ __

10b Adj. resulting from transactions with related organizations (3).....................................
_ 0
_____________________________ __

10c Adj. resulting from transactions with related organizations (3).....................................
_ 0
_____________________________ __

11 Laundry and linen service.........................................................................................................
_ 0
_____________________________ __

12 Cafeteria - employees, guests, etc...................................................................................
_ 0
_____________________________ __

13 Rental of living quarters to employees and others.....................................................
_ 0
_____________________________ __

14 Sale of medical and surgical supplies to other than patients...............................
_ 0
_____________________________ __

15 Sale of drugs to other than patients...............................................................................
_ 0
_____________________________ __

16 Sale of medical records and abstracts..........................................................................
_ 0
_____________________________ __

17 Nursing school (tuition, fees, uniforms, finance charges)........................................
_ 0
_____________________________ __

18 Income from vending machines..........................................................................................
_ 0
_____________________________ __

19 Income from imposition of interest and finance charges.......................................
_ 0
_____________________________ __

20 Payments - Physicians' assumption of operating costs........................................
_ 0
_____________________________ __

21 Undistributed risk pool........................................................................................................
_ 0
_____________________________ __

22 Charges in excess of MAC screens............................................................................
_ 0
_____________________________ __

23 Part B coinsurance on services paid by CMS's MAC/Carriers.........................................
_ 0
_____________________________ __

24 Part B coinsurance on services paid by CMS's MAC/Intermediaries..........................................
_ 0
_____________________________ __

25 Adjustment for physicial therapy costs in excess of limit (4)......................................................................................................................
_ 0
_____________________________ __

26 Reinsurance...........................................................................................................................
_ 0
_____________________________ __

27 Depreciation in excess of limits (Attach worksheet) ........................................................................................................
_ 0
_____________________________ __

28 Noncovered purchased service (Attach worksheet)...................................................................................................................
_ 0
_____________________________ __

29 Medicare Bad Debts
_ 0
_____________________________ __

30 ..................................................................................................................................................................
_ 0
_____________________________ __

31 ..................................................................................................................................................................
_ 0
_____________________________ __

32 ..................................................................................................................................................................
_ 0
_____________________________ __

33 ..................................................................................................................................................................
_ 0
_____________________________ __

34 ..................................................................................................................................................................
_ 0
_____________________________ __

35 ..................................................................................................................................................................
_ 0
_____________________________ __

36 ..................................................................................................................................................................
_ 0
_____________________________ __

37 ..................................................................................................................................................................
_ 0
_____________________________ __

38 ..................................................................................................................................................................
_ 0
_____________________________ __

39 ..................................................................................................................................................................
_ 0
_____________________________ __

40 ..................................................................................................................................................................
_ 0
_____________________________ __

41 ..................................................................................................................................................................
_ 0
_____________________________ __

42 ..................................................................................................................................................................
_ 0
_____________________________ __

43 ..................................................................................................................................................................
_ 0
_____________________________ __

44 ..................................................................................................................................................................
_ 0
_____________________________ __

45 ..................................................................................................................................................................
_ 0
_____________________________ __

46 ..................................................................................................................................................................
_ 0
_____________________________ __

47 ..................................................................................................................................................................
_ 0
_____________________________ __

48 ..................................................................................................................................................................
_ 0
_____________________________ __

49 ..................................................................................................................................................................
_ 0
_____________________________ __


____________




50 Page total...................................................... . . 0




51 a. Subtotal from Page 2........................................... . . 0





b. Subtotal from Page 3........................................... . . 0





c. Subtotal from Page 4........................................... . . 0




____________




52 TOTAL ADJUSTMENTS................................................. . . 0








============




(1) Basis for Adjustment:
(2) Transfer to Worksheet E lines as appropriate.





A = Cost - including applicable overhead, if determinable.
(3) From Worksheet H.





B = Amounts Received - if cost cannot be determined.
(4) See Chapter 4 of HCFA Pub 15-II; attach Worksheet A-8-3.


























FORM CMS 276-08








(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)


















ADJUSTMENTS TO EXPENSES



WORKSHEET G



Name of Plan: 0







Plan #: H-xxxx PERIOD FROM: 12/30/99
PART I





TO: 12/30/99
PAGE 2














BASIS Amount CC LINE

CC

FOR (To Wkst E as COST CENTER NUMBER

LINE DESCRIPTIONS
ADJ(1) appropriate) (Wkst E) (Wkst E)




1 2 3 4











53 _________________________________________________
_ 0
_____________________________ __

54 _________________________________________________
_ 0
_____________________________ __

55 _________________________________________________
_ 0
_____________________________ __

56 _________________________________________________
_ 0
_____________________________ __

57 _________________________________________________
_ 0
_____________________________ __

58 _________________________________________________
_ 0
_____________________________ __

59 _________________________________________________
_ 0
_____________________________ __

60 _________________________________________________
_ 0
_____________________________ __

61 _________________________________________________
_ 0
_____________________________ __

62 _________________________________________________
_ 0
_____________________________ __

63 _________________________________________________
_ 0
_____________________________ __

64 _________________________________________________
_ 0
_____________________________ __

65 _________________________________________________
_ 0
_____________________________ __

66 _________________________________________________
_ 0
_____________________________ __

67 _________________________________________________
_ 0
_____________________________ __

68 _________________________________________________
_ 0
_____________________________ __

69 _________________________________________________
_ 0
_____________________________ __

70 _________________________________________________
_ 0
_____________________________ __

71 _________________________________________________
_ 0
_____________________________ __

72 _________________________________________________
_ 0
_____________________________ __

73 _________________________________________________
_ 0
_____________________________ __

74 _________________________________________________
_ 0
_____________________________ __

75 _________________________________________________
_ 0
_____________________________ __

76 _________________________________________________
_ 0
_____________________________ __

77 _________________________________________________
_ 0
_____________________________ __

78 _________________________________________________
_ 0
_____________________________ __

79 _________________________________________________
_ 0
_____________________________ __

80 _________________________________________________
_ 0
_____________________________ __

81 _________________________________________________
_ 0
_____________________________ __

82 _________________________________________________
_ 0
_____________________________ __

83 _________________________________________________
_ 0
_____________________________ __

84 _________________________________________________
_ 0
_____________________________ __

85 _________________________________________________
_ 0
_____________________________ __

86 _________________________________________________
_ 0
_____________________________ __

87 _________________________________________________
_ 0
_____________________________ __

88 _________________________________________________
_ 0
_____________________________ __

89 _________________________________________________
_ 0
_____________________________ __

90 _________________________________________________
_ 0
_____________________________ __

91 _________________________________________________
_ 0
_____________________________ __

92 _________________________________________________
_ 0
_____________________________ __

93 _________________________________________________
_ 0
_____________________________ __

94 _________________________________________________
_ 0
_____________________________ __

95 _________________________________________________
_ 0
_____________________________ __

96 _________________________________________________
_ 0
_____________________________ __

97 _________________________________________________
_ 0
_____________________________ __

98 _________________________________________________
_ 0
_____________________________ __

99 _________________________________________________
_ 0
_____________________________ __

100 _________________________________________________
_ 0
_____________________________ __

101 _________________________________________________
_ 0
_____________________________ __

102 _________________________________________________
_ 0
_____________________________ __

103 _________________________________________________
_ 0
_____________________________ __

104 _________________________________________________
_ 0
_____________________________ __

105 _________________________________________________
_ 0
_____________________________ __

106 _________________________________________________
_ 0
_____________________________ __

107 Page total (to Page 1, Line 51a)...................................................................................... . . 0








============










(1) Basis for Adjustment:






| A = Cost - including applicable overhead, if determinable.






| B = Amounts Received - if cost cannot be determined.




























FORM CMS 276-08








(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)


















ADJUSTMENTS TO EXPENSES



WORKSHEET G



Name of Plan: 0







Plan #: H-xxxx PERIOD FROM: 12/30/99
PART I





TO: 12/30/99
PAGE 3














BASIS Amount CC LINE

CC

FOR (To Wkst E as COST CENTER NUMBER

LINE DESCRIPTIONS
ADJ(1) appropriate) (Wkst E) (Wkst E)




1 2 3 4











108 _________________________________________________
_ 0
_____________________________ __

109 _________________________________________________
_ 0
_____________________________ __

110 _________________________________________________
_ 0
_____________________________ __

111 _________________________________________________
_ 0
_____________________________ __

112 _________________________________________________
_ 0
_____________________________ __

113 _________________________________________________
_ 0
_____________________________ __

114 _________________________________________________
_ 0
_____________________________ __

115 _________________________________________________
_ 0
_____________________________ __

116 _________________________________________________
_ 0
_____________________________ __

117 _________________________________________________
_ 0
_____________________________ __

118 _________________________________________________
_ 0
_____________________________ __

119 _________________________________________________
_ 0
_____________________________ __

120 _________________________________________________
_ 0
_____________________________ __

121 _________________________________________________
_ 0
_____________________________ __

122 _________________________________________________
_ 0
_____________________________ __

123 _________________________________________________
_ 0
_____________________________ __

124 _________________________________________________
_ 0
_____________________________ __

125 _________________________________________________
_ 0
_____________________________ __

126 _________________________________________________
_ 0
_____________________________ __

127 _________________________________________________
_ 0
_____________________________ __

128 _________________________________________________
_ 0
_____________________________ __

129 _________________________________________________
_ 0
_____________________________ __

130 _________________________________________________
_ 0
_____________________________ __

131 _________________________________________________
_ 0
_____________________________ __

132 _________________________________________________
_ 0
_____________________________ __

133 _________________________________________________
_ 0
_____________________________ __

134 _________________________________________________
_ 0
_____________________________ __

135 _________________________________________________
_ 0
_____________________________ __

136 _________________________________________________
_ 0
_____________________________ __

137 _________________________________________________
_ 0
_____________________________ __

138 _________________________________________________
_ 0
_____________________________ __

139 _________________________________________________
_ 0
_____________________________ __

140 _________________________________________________
_ 0
_____________________________ __

141 _________________________________________________
_ 0
_____________________________ __

142 _________________________________________________
_ 0
_____________________________ __

143 _________________________________________________
_ 0
_____________________________ __

144 _________________________________________________
_ 0
_____________________________ __

145 _________________________________________________
_ 0
_____________________________ __

146 _________________________________________________
_ 0
_____________________________ __

147 _________________________________________________
_ 0
_____________________________ __

148 _________________________________________________
_ 0
_____________________________ __

149 _________________________________________________
_ 0
_____________________________ __

150 _________________________________________________
_ 0
_____________________________ __

151 _________________________________________________
_ 0
_____________________________ __

152 _________________________________________________
_ 0
_____________________________ __

153 _________________________________________________
_ 0
_____________________________ __

154 _________________________________________________
_ 0
_____________________________ __

155 _________________________________________________
_ 0
_____________________________ __

156 _________________________________________________
_ 0
_____________________________ __

157 _________________________________________________
_ 0
_____________________________ __

158 _________________________________________________
_ 0
_____________________________ __

159 _________________________________________________
_ 0
_____________________________ __

160 _________________________________________________
_ 0
_____________________________ __

161 _________________________________________________
_ 0
_____________________________ __

162 Page total (to Page 1, Line 51b)...................................................................................... . . 0








============










(1) Basis for Adjustment:






| A = Cost - including applicable overhead, if determinable.






| B = Amounts Received - if cost cannot be determined.




























FORM CMS 276-08








(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)


















ADJUSTMENTS TO EXPENSES



WORKSHEET G



Name of Plan: 0







Plan #: H-xxxx PERIOD FROM: 12/30/99
PART I





TO: 12/30/99
PAGE 4














BASIS Amount CC LINE

CC

FOR (To Wkst E as COST CENTER NUMBER

LINE DESCRIPTIONS
ADJ(1) appropriate) (Wkst E) (Wkst E)




1 2 3 4











163 _________________________________________________
_ 0
_____________________________ __

164 _________________________________________________
_ 0
_____________________________ __

165 _________________________________________________
_ 0
_____________________________ __

166 _________________________________________________
_ 0
_____________________________ __

167 _________________________________________________
_ 0
_____________________________ __

168 _________________________________________________
_ 0
_____________________________ __

169 _________________________________________________
_ 0
_____________________________ __

170 _________________________________________________
_ 0
_____________________________ __

171 _________________________________________________
_ 0
_____________________________ __

172 _________________________________________________
_ 0
_____________________________ __

173 _________________________________________________
_ 0
_____________________________ __

174 _________________________________________________
_ 0
_____________________________ __

175 _________________________________________________
_ 0
_____________________________ __

176 _________________________________________________
_ 0
_____________________________ __

177 _________________________________________________
_ 0
_____________________________ __

178 _________________________________________________
_ 0
_____________________________ __

179 _________________________________________________
_ 0
_____________________________ __

180 _________________________________________________
_ 0
_____________________________ __

181 _________________________________________________
_ 0
_____________________________ __

182 _________________________________________________
_ 0
_____________________________ __

183 _________________________________________________
_ 0
_____________________________ __

184 _________________________________________________
_ 0
_____________________________ __

185 _________________________________________________
_ 0
_____________________________ __

186 _________________________________________________
_ 0
_____________________________ __

187 _________________________________________________
_ 0
_____________________________ __

188 _________________________________________________
_ 0
_____________________________ __

189 _________________________________________________
_ 0
_____________________________ __

190 _________________________________________________
_ 0
_____________________________ __

191 _________________________________________________
_ 0
_____________________________ __

192 _________________________________________________
_ 0
_____________________________ __

193 _________________________________________________
_ 0
_____________________________ __

194 _________________________________________________
_ 0
_____________________________ __

195 _________________________________________________
_ 0
_____________________________ __

196 _________________________________________________
_ 0
_____________________________ __

197 _________________________________________________
_ 0
_____________________________ __

198 _________________________________________________
_ 0
_____________________________ __

199 _________________________________________________
_ 0
_____________________________ __

200 _________________________________________________
_ 0
_____________________________ __

201 _________________________________________________
_ 0
_____________________________ __

202 _________________________________________________
_ 0
_____________________________ __

203 _________________________________________________
_ 0
_____________________________ __

204 _________________________________________________
_ 0
_____________________________ __

205 _________________________________________________
_ 0
_____________________________ __

206 _________________________________________________
_ 0
_____________________________ __

207 _________________________________________________
_ 0
_____________________________ __

208 _________________________________________________
_ 0
_____________________________ __

209 _________________________________________________
_ 0
_____________________________ __

210 _________________________________________________
_ 0
_____________________________ __

211 _________________________________________________
_ 0
_____________________________ __

212 _________________________________________________
_ 0
_____________________________ __

213 _________________________________________________
_ 0
_____________________________ __

214 _________________________________________________
_ 0
_____________________________ __

215 _________________________________________________
_ 0
_____________________________ __

216 _________________________________________________
_ 0
_____________________________ __

217 Page total (to Page 1, Line 51c)...................................................................................... . . 0








============










(1) Basis for Adjustment:






| A = Cost - including applicable overhead, if determinable.






| B = Amounts Received - if cost cannot be determined.




























FORM CMS 276-08








(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.1)


















SUMMARY OF ADJUSTMENTS TO EXPENSES



WORKSHEET G



Name of Plan: 0


PART II



Plan #: H-xxxx PERIOD FROM: 12/30/99







TO: 12/30/99

























LINE Amount TRANSFER TO CC LINE

CC

NUMBERS (To Wkst E as WORKSHEET E NUMBER

LINE COST CENTER DESCRIPTIONS
FROM appropriate) LINE # AS SHOWN Wkst E




PART I







1 2
3 4













1 Inpatient Hospitals……………………………… . ___________ 0
1

2 Outpatient Hospitals………………………….. . ___________ 0
2

3 Skilled Nursing Facilities................................. . ___________ 0
3

4 Home Health Agencies...................................... . ___________ 0
4

5 Clinics.............................................................................. . ___________ 0
5

6 Physician Groups....................................... . ___________ 0
6

7 Individual Physicians..................................... . ___________ 0
7

8 Certified Labs............................................... . ___________ 0
8

9 X-Ray Units................................................... . ___________ 0
9

10 ESRD Facilities........................................................................................................................ . ___________ 0
10

11 Durable Medical Equipment.............................................................................................................. . ___________ 0
11

12 Ambulances................................................... . ___________ 0
12

13 Pharmacy (Outpatient).................................... . ___________ 0
13

13a Pharmacy-Medicare Covered Rx....... . ___________ 0
13

14 Emergency-Urgently Needed Svcs................................................................................................. . ___________ 0
14

15 Mental Health Services............................ . ___________ 0
15

16 DED+CO on Svcs pd by the CMS MAC…………………………...................................................
___________ 0
16

17 Other - Medicare Bad Debts...… . ___________ 0
17

18 Other - Blood Deductible.....… . ___________ 0
18

19 Other - (Specify)...…….......… . ___________ 0
19

20 Other - (Specify)...…….......… . ___________ 0
20

21 Other - (Specify)...…….......… . ___________ 0
21

22 Other - (Specify)...…….......… . ___________ 0
22

23 Other - (Specify)...…….......… . ___________ 0
23

24





24

25 Plan Administration...................................... . ___________ 0
25

26 Special Admin Costs..................................... . ___________ 0
26

27




27

28 Admin & General Costs...................................................................... . ___________ 0
28





____________



29 Total Adjustments (Lines 1 thru 28).............................................................................................................

0
29





============





































































































FORM CMS 276-08







(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2309.2)
















Sheet 6: Worksheet H



STATEMENT OF COSTS OF SERVICES FROM RELATED ORGANIZATIONS





WORKSHEET H



Name of Plan: 0
PERIOD FROM:
12/30/99



Plan #: H-xxxx
TO:
12/30/99



A. Are there any costs included on Worksheet E which resulted from transactions with related organizations?










Select
(If "YES", complete Parts B and C.)






B. Costs incurred and adjustments required as a result of transactions with related organizations.
















AMOUNT
NET







ALLOWABLE
ADJUSTMENTS (1)


LINE COST CENTER (Worksheet E) EXPENSE ITEMS
AMOUNT
IN COST
(5)


(Wkst E) 1 2
3
4
(5 = 4 - 3)

1 _____ ___________________________ ___________________________
0
0
0

2 _____ ___________________________ ___________________________
0
0
0

3 _____ ___________________________ ___________________________
0
0
0

4 _____ ___________________________ ___________________________
0
0
0

5 _____ ___________________________ ___________________________
0
0
0

6 _____ ___________________________ ___________________________
0
0
0

7 _____ ___________________________ ___________________________
0
0
0

8 _____ ___________________________ ___________________________
0
0
0

9 _____ ___________________________ ___________________________
0
0
0

10 _____ ___________________________ ___________________________
0
0
0

11 _____ ___________________________ ___________________________
0
0
0

12 _____ ___________________________ ___________________________
0
0
0

13 _____ ___________________________ ___________________________
0
0
0

14 _____ ___________________________ ___________________________
0
0
0

15 _____ ___________________________ ___________________________
0
0
0

16 _____ ___________________________ ___________________________
0
0
0





_____________
_____________
_____________

17
TOTALS.........................................................................……………………………………………………………………………..

0
0
0






=============
=============
=============

(1) Transfer the sum of this column to Worksheet G, Part I, Column 2 line 10





















C. Interrelationship of Plan to related organization(s):











The Secretary, by virtue of authority granted under section 1814(b)(1) of the Health Insurance for the Aged and Disabled Act,










required organizations to furnish the information requested on Part C of this worksheet. The information will be used by the Health










Care Financing Administration in determining that the costs applicable to services, facilities and supplies furnished by










organizations related to the Plan by common ownership or control, represent reasonable costs as determined under section 1861 of the










Health Insurance for the Aged and Disabled Act. If the Plan does not provide all or any part of the requested information, the cost










report will be considered incomplete and not acceptable for purposes of claiming reimbursement under Title XVIII.

























----------RELATED ORGANIZATION(S)--------





SYMBOL (2) NAME OF INDIVIDUAL OWNERSHIP OF PLAN
ORGANIZATION
OWNERSHIP
TYPE OF





NAME
%
BUSINESS

1 2 3
4
5
6













1 _ ________________________________ _______________________________
______________
0.00%
_____________

2 _ ________________________________ _______________________________
______________
0.00%
_____________

3 _ ________________________________ _______________________________
______________
0.00%
_____________

4 _ ________________________________ _______________________________
______________
0.00%
_____________

5 _ ________________________________ _______________________________
______________
0.00%
_____________

6 _ ________________________________ _______________________________
______________
0.00%
_____________

7 _ ________________________________ _______________________________
______________
0.00%
_____________

8 _ ________________________________ _______________________________
______________
0.00%
_____________

9 _ ________________________________ _______________________________
______________
0.00%
_____________

10 _ ________________________________ _______________________________
______________
0.00%
_____________

11 _ ________________________________ _______________________________
______________
0.00%
_____________

12 _ ________________________________ _______________________________
______________
0.00%
_____________

13 _ ________________________________ _______________________________
______________
0.00%
_____________

14 _ ________________________________ _______________________________
______________
0.00%
_____________

15 _ ________________________________ _______________________________
______________
0.00%
_____________

16 _ ________________________________ _______________________________
______________
0.00%
_____________

17 _ ________________________________ _______________________________
______________
0.00%
_____________














(2) Use the following symbols to indicate the interrelationship of the Plan to related organizations:









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









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









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










in related organization.









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









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










financial interest in the Plan.









G Other (financial or nonfinancial) specify.





















FORM CMS 276-08










(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2310)




















Sheet 7: Worksheet I


ADMINISTRATIVE AND GENERAL COST ALLOCATION











WORKSHEET I


















Name of Plan:
0








PART I


Plan #: #REF! H-xxxx


PERIOD FROM:
12/30/99











TO:
12/30/99



















































1
2
3
4 5 6 7



EMPLOYEE
STATISTICS
PHARMACY
OTHER TOTALS POOLED TOTALS




BENEFITS
& DATA
& (SPECIFY) (Sum Cols ADMIN & GEN (Col 5 +
COST CENTER (Salaries)
PROCESSING
SUPPLIES

1 Thru 4) COSTS Col 6)






(Time Spent)
(Cost Req's)





















1 Inpatient Hospitals ……………….
0
0
0
0
0 0 0

2 Outpatient Hospitals …………….
0
0
0
0
0 0 0

3 Skilled Nursing Facilities.......….…
0
0
0
0
0 0 0

4 Home Health Agencies........….….
0
0
0
0
0 0 0

5 Clinics..........……….........….......…
0
0
0
0
0 0 0

6 Physician Groups.......................…
0
0
0
0
0 0 0

7 Individual Physicians.....…...….…
0
0
0
0
0 0 0

8 Certified Labs..................…......…
0
0
0
0
0 0 0

9 X-Ray Units....................……....…
0
0
0
0
0 0 0

10 ESRD Facilities.........................…
0
0
0
0
0 0 0

11 Durable Medical Equipment.......…
0
0
0
0
0 0 0

12 Ambulance...............……….......…
0
0
0
0
0 0 0

13 Pharmacy (Outpatient).......…...…
0
0
0
0
0 0 0

13a Pharmacy-Medicare Covered Rx
0
0
0
0
0 0 0

14 Emergency-Urgent Needed Svcs..
0
0
0
0
0 0 0

15 Mental Health Services....….……
0
0
0
0
0 0 0

16 DED+CO pd by MAC/Carrier/Inter
0
0
0
0
0 0 0

17 Other - Medicare Bad Debts...…
0
0
0
0
0 0 0

18 Other - Blood Deductible.....…
0
0
0
0
0 0 0

19 Other - (Specify)...…….......…
0
0
0
0
0 0 0

20 Other - (Specify)...…….......…
0
0
0
0
0 0 0

21 Other - (Specify)...…….......…
0
0
0
0
0 0 0

22 Other - (Specify)...…….......…
0
0
0
0
0 0 0

23 Other - (Specify)...…….......…
0
0
0
0
0 0 0




___________ ___________ ___________ ___________ ___________ ___________ ___________

24 Subtotal (Sum of Lines 1 thru 23)...........…
0 0 0 0 0 0 0














25 Plan Administration....................................




0
0
0

26 Special Administrative Costs............…






0
0
0



___________ ___________ ___________ ___________ ___________ ___________ ___________

27 Subtotal (Sum of 25 and 26) ...................




0 0
0




___________ ___________ ___________ ___________ ___________ ___________ ___________


Total (Sum of Lines 24 & 27)...........................
0 0 0 0 0 0 0















28 Admin & General Costs...............................
0
0
0
0
0 0 0




___________ ___________ ___________ ___________ ___________ ___________ ___________

29 Net A&G Costs (Lines 24+27+28)....................................
0
0
0
0
0 0 0




=========== =========== ====== =========== ============ ============ =========== ===========
















30 Computation - Fr Worksheet, Col........
Fr Wkst I,
Fr Wkst I,
Fr Wkst I,
Fr Wkst I,

Fr Wkst I,





Pt II, Col 1
Pt II, Col 2
Pt II, Col 3
Pt II, Col 4

Pt II, Col 7


















31 To Worksheet, Column........................








To Wkst I,
To Wkst E,










Pt II, Col 6
Col 5


















FORM CMS 276-08













(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2311.1)













































































ADMINISTRATIVE AND GENERAL STATISTICS











WORKSHEET I


















Name of Plan: #REF! 0








PART II


Plan #: #REF! H-xxxx


PERIOD FROM:
12/30/99











TO:
12/30/99























































EMPLOYEE
STATISTICS
PHARMACY
OTHER TOTALS TOTALS POOLED



BENEFITS
& DATA
& (SPECIFY) (From (From ADMIN & GEN


COST CENTER
(Salaries)
PROCESSING
SUPPLIES

Worksheet E Wkst I, STATS





(Time Spent)
(Cost Req's)

Column 4) Pt I, Col 5) (Cols 5+6)




1 2 3 4 5 6 7
















1 Inpatient Hospitals ………………. 0
0
0
0
0 0 0

2 Outpatient Hospitals …………….
0
0
0
0
0 0 0

3 Skilled Nursing Facilities.......….… 0
0
0
0
0 0 0

4 Home Health Agencies........….…. 0
0
0
0
0 0 0

5 Clinics..........……….........….......… 0
0
0
0
0 0 0

6 Physician Groups.......................… 0
0
0
0
0 0 0

7 Individual Physicians.....…...….… 0
0
0
0
0 0 0

8 Certified Labs..................…......… 0
0
0
0
0 0 0

9 X-Ray Units....................……....… 0
0
0
0
0 0 0

10 ESRD Facilities.........................… 0
0
0
0
0 0 0

11 Durable Medical Equipment.......… 0
0
0
0
0 0 0

12 Ambulance...............……….......… 0
0
0
0
0 0 0

13 Pharmacy (Outpatient).......…...… 0
0
0
0
0 0 0

13a Pharmacy-Medicare Covered Rx 0
0
0
0
0 0 0

14 Emergency-Urgent Needed Svcs.. 0
0
0
0
0 0 0

15 Mental Health Services....….…… 0
0
0
0
0 0 0

16 DED+CO pd by MAC/Carrier/Inter 0
0
0
0
0 0 0

17 Other - Medicare Bad Debts...… 0
0
0
0
0 0 0

18 Other - Blood Deductible.....… 0
0
0
0
0 0 0

19 Other - (Specify)...…….......… 0
0
0
0
0 0 0

20 Other - (Specify)...…….......… 0
0
0
0
0 0 0

21 Other - (Specify)...…….......… 0
0
0
0
0 0 0

22 Other - (Specify)...…….......… 0
0
0
0
0 0 0

23 Other - (Specify)...…….......… 0
0
0
0
0 0 0




___________
___________
___________
___________
___________ ___________ ___________

24 Subtotal (Sum of Lines 1 thru 23)...........… 0
0
0
0
0 0 0














25 Plan Administration....................................





0





26 Special Administrative Costs............…





0







___________
___________
___________
___________





27 Subtotal (Sum of 25 and 26) ...................





0








___________
___________
___________
___________
___________ ___________ ___________


Total (Sum of Lines 24 & 27).................... 0
0
0
0
0 0 0















28 Administrative & General Costs..........................................















___________
___________
___________
___________
___________ ___________ ___________

29 TOTAL STATS (Sum of 24 & 27)........... 0
0
0
0
0 0 0




===========
============
============
=============
============= ============= ============













Col 5 - (1+2+3+4)

30 COSTS TO BE ALLOCATED..................... 0
0
0
0
0
0


(Input here)





























31 UNIT COST MULTIPLIER.......................................... 0.000000
0.000000
0.00000
0.000000


0.000000

(Line 30 / Line 29)






























FORM CMS 276-08














(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2311.1)













Sheet 8: Worksheet J



SUMMARY OF PROVIDER COSTS










WORKSHEET J
































PAGE 1



Name of Plan:
0













Plan #:
H-xxxx


PERIOD FROM:
12/30/99













TO:
12/30/99














































1
2 3 4 5








PART A
PART B



PROVIDERS
PROVIDER
REIMBURSABLE DEDUCTIBLE + REIMBURSABLE DEDUCTIBLE







NUMBER
PART A COINSURANCE PART B























1 Medicare Memb Mos (WS D, Pt II, Sec E, Ln 3)


0 0 0 0









=========
=========
=========
=========





2 Hospitals









3 __________________________________
____________
0
0
0
0





4 __________________________________
____________
0
0
0
0





5 __________________________________
____________
0
0
0
0





6 __________________________________
____________
0
0
0
0





7 __________________________________
____________
0
0
0
0





8 __________________________________
____________
0
0
0
0





9 __________________________________
____________
0
0
0
0





10 __________________________________
____________
0
0
0
0





11 __________________________________
____________
0
0
0
0





12 __________________________________
____________
0
0
0
0





13 __________________________________
____________
0
0
0
0





14 __________________________________
____________
0
0
0
0





15 __________________________________
____________
0
0
0
0





16 __________________________________
____________
0
0
0
0





17 __________________________________
____________
0
0
0
0





18 __________________________________
____________
0
0
0
0





19 __________________________________
____________
0
0
0
0





20 __________________________________
____________
0
0
0
0





21 __________________________________
____________
0
0
0
0





22 __________________________________
____________
0
0
0
0





23 __________________________________
____________
0
0
0
0





24 __________________________________
____________
0
0
0
0





25 __________________________________
____________
0
0
0
0





26 __________________________________
____________
0
0
0
0





27 __________________________________
____________
0
0
0
0





28 __________________________________
____________
0
0
0
0





29 __________________________________
____________
0
0
0
0





30 __________________________________
____________
0
0
0
0





31 __________________________________
____________
0
0
0
0





32 __________________________________
____________
0
0
0
0





33 __________________________________
____________
0
0
0
0





34 __________________________________
____________
0
0
0
0





35 __________________________________
____________
0
0
0
0





36 __________________________________
____________
0
0
0
0





37 __________________________________
____________
0
0
0
0





38 __________________________________
____________
0
0
0
0





39 __________________________________
____________
0
0
0
0





40 __________________________________
____________
0
0
0
0





41 __________________________________
____________
0
0
0
0





42 __________________________________
____________
0
0
0
0





43 __________________________________
____________
0
0
0
0





44 __________________________________
____________
0
0
0
0





45 __________________________________
____________
0
0
0
0





46 __________________________________
____________
0
0
0
0





47 __________________________________
____________
0
0
0
0





48 Total Hospital ………………………………………………………………………………………


0
0
0 0 0








=========
=========
=========
=========





















49 Cost PMPM (Line 48 / Line 1)......................................................................


0.0000
0.0000
0.0000 0.0000








=========
=========
=========
=========
























































50 Enter on Worksheet, Col, Line.....................................................................


M, 2, 1
M, 2, 1&8
M, 3, 1
M, 3, 1










































FORM CMS 276-08
















(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2312)

































SUMMARY OF PROVIDER COSTS










WORKSHEET J















(Continued)
















PAGE 2




Name of Plan:
0














Plan #:
H-xxxx


PERIOD FROM:
12/30/99













TO:
12/30/99














































1
2 3 4 5








PART A
PART B





PROVIDERS
PROVIDER
REIMBURSABLE DEDUCTIBLE+ REIMBURSABLE DEDUCTIBLE







NUMBER
PART A COINSURANCE PART B























51 Skilled Nursing Facilities:







52 __________________________________
____________
0
0
0
0





53 __________________________________
____________
0
0
0
0





54 __________________________________
____________
0
0
0
0





55 __________________________________
____________
0
0
0
0





56 __________________________________
____________
0
0
0
0





57 __________________________________
____________
0
0
0
0





58 __________________________________
____________
0
0
0
0





59 __________________________________
____________
0
0
0
0





60 __________________________________
____________
0
0
0
0





61 __________________________________
____________
0
0
0
0





62 Total (Sum of Lines 52 thru 61)……………………………………………………………… 0
0
0
0










=========
=========
=========
=========





63 Cost PMPM (Line 63 / Line 1)......................................................................


0.0000
0.0000
0.0000
0.0000























64 Enter on Wkst, Col, Line.................................................................................


M, 2, 2 M, 2, 2&8 M, 3, 2 M, 3, 2






















65 Home Health Agencies:















66 __________________________________
____________













67 __________________________________
____________













68 __________________________________
____________













69 __________________________________
____________













70 __________________________________
____________













71 __________________________________
____________













72 __________________________________
____________













73 __________________________________
____________













74 __________________________________
____________













75 Total (Sum of Lines 68 thru 76)………………………………………………………………






























76 Cost PMPM (Line 78 / Line 1)......................................................................

































77 Enter on Wkst, Col, Line.................................................................................

































78 Other Providers (Specify Type):







79 __________________________________
____________
0
0
0
0





80 __________________________________
____________
0
0
0
0





81 __________________________________
____________
0
0
0
0





82 __________________________________
____________
0
0
0
0





83 __________________________________
____________
0
0
0
0





84 __________________________________
____________
0
0
0
0





85 __________________________________
____________
0
0
0
0





86 __________________________________
____________
0
0
0
0





87 __________________________________
____________
0
0
0
0





88 __________________________________
____________
0
0
0
0





89 __________________________________
____________
0
0
0
0










_____________
_____________
_____________
_____________





90 Total (Sum Lines 82 thru 92)..........................................................................


0
0
0
0










=========
=========
=========
========





91 Cost PMPM (Line 93 / Line 1)......................................................................


0.0000
0.0000
0.0000
0.0000























92 Enter on Wkst, Col, Line................................................................................


M, 2, 4
M, 2, 4&8
M, 3, 4
M, 3, 4










































FORM CMS 276-08
















(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2312)















Sheet 9: Worksheet K



SUMMARY APPORTIONMENT OF NON-PROVIDER COSTS


















































Name of Plan:
0













Plan #:
H-xxxx


PERIOD FROM:
12/30/99













TO:
12/30/99













































1
2 3 4 5 6 7




COVERED MED SUBPART E RATIO TOTAL COSTS MEDICARE


COST CENTERS STATISTIC
TOTAL ENROLLEE LIMITS IF Col 3 or Col (Fr Wkst E COSTS



USED
STATISTICS STATISTICS APPLICABLE 4 / Col 2 Col 6) Col 5 X Col 6



















1 Clinics (furnished directly)............................................. ___________
0
0


0.00000

0

2 Physician Groups:














3 _________________________________ ___________
0
0
0
0.00000 0
0

4 _________________________________ ___________
0
0
0
0.00000 0
0

5 _________________________________ ___________
0
0
0
0.00000 0
0 0

6 _________________________________ ___________
0
0
0
0.00000 0
0 0

7 Individual Physicians....................................................... ___________
0
0
0
0.00000 0
0 0

8 Certified Labs.................................................................... ___________
0
0
0
0.00000 0
0 0

9 _________________________________ ___________
0
0
0
0.00000 0
0 0

10 _________________________________ ___________
0
0
0
0.00000 0
0 0

11 X-Ray Units......................................................................... ___________
0
0
0
0.00000 0
0 0

12 _________________________________ ___________
0
0
0
0.00000 0
0 0

13 _________________________________ ___________
0
0
0
0.00000 0
0 0

14 ESRD Facilities................................................................ ___________
0
0
0
0.00000 0
0 0

15 _________________________________ ___________
0
0
0
0.00000 0
0 0

16 Durable Medical Equipment......................................... ___________
0
0
0
0.00000 0
0 0

17 Ambulance.......................................................................... ___________
0
0
0
0.00000 0
0 0

18 Emergency-Urgently Needed Svcs............................ ___________
0
0
0
0.00000 0
0 0

19 Professional Component - Mental Health…….. ___________
0
0
0
0.00000 0
0 0

20 Mental Health Svcs - Non-Prof Component…… ___________
0
0
0
0.00000 0
0 0

21 _________________________________ ___________
0
0
0
0.00000 0
0 0

22 _________________________________ ___________
0
0
0
0.00000 0
0 0

23 _________________________________ ___________
0
0
0
0.00000 0
0 0

24 _________________________________ ___________
0
0
0
0.00000 0
0 0

25 _________________________________ ___________
0
0
0
0.00000 0
0 0

26 _________________________________ ___________
0
0
0
0.00000 0
0 0

27 _________________________________ ___________
0
0
0
0.00000 0
0 0

28 _________________________________ ___________
0
0
0
0.00000 0
0 0

29 _________________________________ ___________
0
0
0
0.00000 0
0 0

30 _________________________________ ___________
0
0
0
0.00000 0
0 0

31 _________________________________ ___________
0
0
0
0.00000 0
0 0

32 _________________________________ ___________
0
0
0
0.00000 0
0 0

33 _________________________________ ___________
0
0
0
0.00000 0
0 0

34 _________________________________ ___________
0
0
0
0.00000 0
0 0



















35 Total (Sum Lines 1 thru 34).............................................................................











0 0















=========

36 Member Months - Part B (W/S D, Part II, Pg 2, Pt E, Col 2, Line 1)..........................................................................................................











0















=========

37 Cost PMPM (Line 51 / Line 52)..............................................................…..











0.0000


















38 Enter on Worksheet, Col, Line..................................................................….











M, 3, 5




















FORM CMS 276-08
















(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2313)















Sheet 10: Worksheet L



SUMMARY OF MISCELLANEOUS ITEMS












WORKSHEET L




































Name of Plan:
0













Plan #:
H-xxxx


PERIOD FROM:
12/30/99













TO:
12/30/99
















































1
2
3
4
5
6









NON-





DESCRIPTION


MEDICARE
MEDICARE
TOTAL
MEDICARE


ENTER ON





PART A
PART B
Col 1+Col 2
Col 5 - Col 2
TOTAL
WKST LINE


















1 Member Months (Wkst D, Pt II, Pg 2, Pt E, Col 1 and 2, Ln 1)

0
0


0





2














3 Plan Administration (Wkst E, Col 6, Ln 21)................................................









0



4 Cost PMPM (Line 3 / Line 1)..........................................................................

0.0000
0.0000




0.0000
M 6

5














6 Special Admin Costs (Wkst E, Col 6, Ln 22)............................................




0









7 Cost PMPM (Line 6 / Line 1)..........................................................................



0.0000






M 15

8















9 Allowable Medicare Bad Debts (Wkst E, Col 6, Line 17).....................



0







10 Cost PMPM (Line 9 / Line 1)..........................................................................

0.0000
0.0000
0.0000




M 16

11















12 Part B Blood Deductible.................................................................................





0







13 Cost PMPM (Line 12 / Line 1).........................................................................



0.0000
0.0000




M 10

14














15 Third Party Insurer Revenue (see Instructions)......................................





0







16 Cost PMPM (Line 15 / Line 1)........................................................................

0.0000
0.0000
0.0000




M 18

17















18 Part B Ded on Svcs Pd by CMS Carrier (Wkst E, Col 9, Ln 16)......




0
0







19 Cost PMPM (Line 18 / Line 1).........................................................................




0.0000
0.0000




M 5a

20















21 Pro Component of Mental Hlth Svcs (W/S K, Line 19)........................



0 0







22 Line 21 times 37.5%.............................................................................................




0
0







23 Cost PMPM (Line 22 / Line 1)........................................................................




0.0000
0.0000




M 11




















FORM CMS 276-08
















(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2314)















Sheet 11: Worksheet M


SETTLEMENT SHEET Name of Plan:


PERIOD FROM:
12/30/99 WORKSHEET M




Plan #: H-xxxx


TO:
12/30/99




























DESCRIPTION

FROM
MEDICARE
MEDICARE
TOTAL




WKST
PART A
PART B
Col 2 + Col 3





1
2
3
4

1 Hospital Costs………………………………………………………………………………………………………….........

J
0.0000
0.0000
0.0000

2 Skilled Nursing Facility Costs………………………………………………………………………………………..

J
0.0000
0.0000
0.0000

3 Home Health Agency Costs………………………………………………………………………………………….

J
0.0000
0.0000
0.0000

4 Other Provider's Costs ………………………………………………………………………………………………….

J
0.0000
0.0000
0.0000

5 Nonprovider Costs………………………………………………………………………………………………………….

K


0.0000
0.0000

5a Part B Deduct on Svcs Pd by CMS' Carriers/Intermediaries/MAC ………..………………………………………………………..

L


0.0000
0.0000

6 Plan Administration Costs…………………………………………………………………………………………….

L
0.0000
0.0000
0.0000







___________
___________



7 Totals (Sum Lines 1 - 6)………………………………………………………………………………………………….



0.0000
0.0000
0.0000












8 Part A Deductible and Coinsurance…………………………………………………………………………….

J
0


0.0000

9 Part B Standard Deductible……………………………………………………………………………………………






0.0000

10 Part B Blood Deductible…………………………………………………………………………………………………

L


0.0000
0.0000

11 Copayment on Mental Health Services……………………………………………………………………….

L


0.0000
0.0000






___________
___________



12 Line 7 Minus (The Sum of Lines 8 - 11)………………………………………………………………………….


0.0000
0.0000
0.0000











13 20% of (Col 3 Line 12 minus Col 3 Line 3)…………………………………………………………………….




0.0000
0.0000






___________
___________



14 Reimbursable Costs (Line 12 Minus Line 13)……………………………………………………………….


0.0000
0.0000
0.0000

15 Special Administrative Costs……………………………………………………………………………………….

L


0.0000
0.0000

16 Medicare Bad Debts……………………………………………………………………………………………………….

L
0.0000
0.0000
0.0000

16a Part B Cost Not Subject to Coinsurance……………………………………………………………………………………………………….



0.0000


0.0000

17 Total (Sum Lines 14 thru 16a)…………………………………………………………………………………………….


0.0000
0.0000
0.0000

18 Less: Third Party Insurer Revenue………………………………………………………………………………..

L
0.0000
0.0000
0.0000






___________
___________



19 Medicare Costs (Line 17 minus Line 18)……………………………………………………………………….


0.0000
0.0000
0.0000

20 Medicare Primary Member Months…………………………………………………………………………….

D
0
0









___________
___________



21 Reimbursable Costs (Line 19 X Line 20)……………………………………………………………………….


0
0
0

22 Interim Payments (by) to HCFA…………………………………………………………………………………….




















___________

23 Balance (Line 21 minus Line 22)…………………………………………………………………………………….







0


Adjustments from Prior Years:










24 ____________________________________________










25 ____________________________________________










26 ____________________________________________




















___________

27 Balance Due Plan (CMS) (Line 23 + or - Lines 24-26).....……………………………………….







0











=========














FORM CMS 276-08











(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2315)











Sheet 12: Worksheet N

MEDICARE PREMIUM RECONCILIATION







WORKSHEET N













Name of Plan: 0


Period From: 12/30/99



Plan Number: H-xxxx


To: 12/30/99












Under and Over Collection of Medicare Premiums - Current Year

















Member Cost Per
Premium Determinations Covered by this Part





Totals Months Member Month Line







1 2 3
0 Total Medicare Member Months




XXXXXXXXXXXX
XXXXXXXXXXXX 0











1 Total Premiums/Dues collected during the period





XXXXXXXXXXXX - 1
2 Total Copayments collected during the period





XXXXXXXXXXXX - 2








XXXXXXXXXXXX

3 Total Collections (Line 1 plus Line 2)




- XXXXXXXXXXXX - 3








XXXXXXXXXXXX

4 Less: Accounts Receivable for premiums/dues and copayments (beg of period)





XXXXXXXXXXXX - 4








XXXXXXXXXXXX

5 Net Collections for period (Line 3 minus Line 4)




- XXXXXXXXXXXX - 5
6 Add: Accounts Receivable for premiums/dues and copayments (end of period)





XXXXXXXXXXXX - 6








XXXXXXXXXXXX

7 Net Collections and Amounts to be Collected (Line 5 plus Line 6)




- XXXXXXXXXXXX - 7






















8 Total Medicare Deductible and Coinsurance from Cost Report:







8

a. Deductible and copayments (Worksheet M, Col 2 + 3 , Sum lines 8 thru 11)




XXXXXXXXXXXX XXXXXXXXXXXX
8a

b. Part B Coinsurance (Worksheet M, Col 3, Line 13)




XXXXXXXXXXXX XXXXXXXXXXXX
8b

c. Part B Coinsurance on services paid by CMS (Worksheet G, Col 2, Lines 23 + 24)




XXXXXXXXXXXX XXXXXXXXXXXX
8c












d. Total (Sum of Lines 8a thru 8c)




XXXXXXXXXXXX XXXXXXXXXXXX 0.0000 8d











9 Voluntary under collection for the period (Worksheet B, Part II, Line 7)




XXXXXXXXXXXX XXXXXXXXXXXX
9
10 Over collection from prior period (Prior Worksheet B, Part II, Excess of Ln 6 over Ln 5)




XXXXXXXXXXXX XXXXXXXXXXXX
10











11 Total amount allowed to be charged (Line 8d minus sum of Lines 9 and 10)




XXXXXXXXXXXX XXXXXXXXXXXX 0.0000 11











12 Under (over) collection for the period (Line 11 minus Line 7)




XXXXXXXXXXXX XXXXXXXXXXXX 0.0000 12











FORM CMS 276-08









(INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 2316)










Sheet 13: Special Administration Costs

Special Administration Costs Amount
Accretion/Deletion Cost
Certification Cost
Special Studies
Other (Specify)
Total Special Administration Cost 0

Sheet 14: Subpart E Limits


SUBPART E LIMITS




















Name of Plan:
0


Period From:
0

Plan #:
H-xxxx


To:
0











Is this Plan an HCPP subject to the Subpart E Limits?






















COMPARABLE CARRIER PAYMENTS








COST CENTERS










1 Physician Groups:








2 _________________________________




3 _________________________________




4 _________________________________




5 _________________________________




6 Individual Physicians.....................................................................................................................




7 Certified Labs...................................................................................................................................




8 _________________________________




9 _________________________________




10 X-Ray Units.......................................................................................................................................




11 _________________________________




12 _________________________________




13 ESRD Facilities...............................................................................................................................




14 _________________________________




15 Durable Medical Equipment........................................................................................................




16 Ambulance.........................................................................................................................................




17 Emergency-Urgently Needed Svcs..........................................................................................




18 Professional Component - Mental Health…………………………………………………………….…..




19 Mental Health Svcs - Non-Prof Component……………………………………………………….……




20 _________________________________




21 _________________________________




22 _________________________________




23 _________________________________




24 _________________________________




25 _________________________________




26 _________________________________




27 _________________________________




28 _________________________________




29 _________________________________




30 _________________________________




31 _________________________________




32 _________________________________




33 _________________________________



































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































































Yes










No
File Typeapplication/vnd.ms-excel
Authorbunting
Last Modified ByCMS
File Modified2009-08-17
File Created2001-08-31

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