CMS-276 4th Quarter Cost Report

Prepaid Health Plan Cost Report

CMS-276.4th Quarter Report.xls

Prepaid Health Plan Cost Report (HMO)

OMB: 0938-0165

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0165 can be found here:

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 Type	application/vnd.ms-excel
Author	bunting
Last Modified By	CMS
File Modified	2009-08-17
File Created	2001-08-31