Hrsa_chgme_99-1-2

Children's Hospital Graduate Medical Eduction Program

hrsa99_1_2.xls

Children's Hospital Graduate Medical Eduction Payment Program

OMB: 0915-0247

Document [xlsx]
Download: xlsx | pdf

Overview

HRSA 99 -1 Cover Page
HRSA 99-1 Page 1 of 4
HRSA 99-1 Page 2 of 4
HRSA 99-1 Page 3 of 4
HRSA 99-1 Page 4 of 4
HRSA 99-2 Cover Page
HRSA 99-2 Page 1 of 1


Sheet 1: HRSA 99 -1 Cover Page

Department of Health and Human Services






OMB N0. 0915-0247
Health Resources and Services Administration





Expiration Date: 03/31/2010














CHILDREN’S HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM

APPLICATION FORM HRSA 99-1


















































































Public Burden Statement





An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915 0247. Public reporting burden for the applicant for this collection of information is estimated to average 69 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14 33, Rockville, Maryland, 20857.




























Sheet 2: HRSA 99-1 Page 1 of 4

Department of Health and Human Services





OMB N0. 0915-0247
Health Resources and Services Administration




Expiration Date: 03/31/2010









Children's Hospitals Graduate Medical Education Payment Program Determination of Weighted and Unweighted Resident FTE Counts
Name of Applicant:
City:
State:
Zip Code:
Medicare Provider Number:
Fiscal Year in which applying for funding: FFY
Type of Application (check box to the left) _____Initial Application
_____Reconciliation Application
Are you a new children's hospital that has not completed three full Medicare cost reporting periods? (Please place 'n' for no or 'y' for yes in the cell to the right)
Section 1 DETERMINATION OF RESIDENT FTE CAP FOR THE HOSPITAL'S MOST RECENT COST REPORTING PERIOD ENDING ON OR BEFORE DECEMBER 31, 1996 To be completed by hospital For CHGME FI Use Only
HOSPITAL DATA MCR DATA FI DATA
1.01 Inclusive dates of the subject cost reporting period (From)

(To)
1.02 Status of MCR


1.03 Unweighted resident FTE count for allopathic and osteopathic programs (from the 1996 cap year) 0.00 0.00 0.00
Section 2 AVERAGE OF UNWEIGHTED RESIDENT FTE COUNTS HOSPITAL DATA MCR DATA FI DATA
2.01 Total unweighted resident FTE count for the hospital's most recently completed cost reporting period 0.00 0.00 0.00
2.02 Total unweighted resident FTE count for the hospital's prior cost reporting period 0.00 0.00 0.00
2.03 Total unweighted resident FTE count for the hospital's penultimate cost reporting period 0.00 0.00 0.00
2.04 Rolling average of unweighted resident FTE count 0.00 0.00 0.00
2.05 Add On: Unweighted resident FTE count meeting the criteria for an exception 0.00 0.00 0.00
2.06 Adjusted rolling average of unweighted resident FTE count 0.00 0.00 0.00
2.07 Add On: Unweighted resident FTE count from MMA §422 0.00 0.00 0.00
2.08 Grand Total: Unweighted resident FTE Count 0.00 0.00 0.00
Section 3 AVERAGE OF WEIGHTED RESIDENT FTE COUNTS HOSPITAL DATA MCR DATA FI DATA
3.01 Total weighted resident FTE count for the hospital's most recently completed cost reporting period 0.00 0.00 0.00
3.02 Total weighted resident FTE count for the hospital's prior cost reporting period 0.00 0.00 0.00
3.03 Total weighted resident FTE count for the hospital's penultimate cost reporting period 0.00 0.00 0.00
3.04 Rolling average of weighted resident FTE count 0.00 0.00 0.00
3.05 Add On: Weighted resident FTE count meeting the criteria for an exception 0.00 0.00 0.00
3.06 Adjusted rolling average of weighted resident FTE count 0.00 0.00 0.00
3.07 Add On: Weighted resident FTE count from MMA §422 0.00 0.00 0.00
3.08 Grand Total: Weighted resident FTE Count 0.00 0.00 0.00



























HRSA 99-1 Page 1 of 4





Created in MS Excel 7.0
(Rev. 03-2007)








Sheet 3: HRSA 99-1 Page 2 of 4

Department of Health and Human Services





OMB N0. 0915-0247
Health Resources and Services Administration




Expiration Date: 03/31/2010









Children's Hospitals Graduate Medical Education Payment Program Determination of Weighted and Unweighted Resident FTE Counts
Name of Applicant: 0
City: 0 State: 0 Zip Code: 0
Medicare Provider Number: 0
Fiscal Year in which applying for funding: FFY
Type of Application (check box to the left) ______Initial Application
_____Reconciliation Application
Section 4 DETERMINATION OF FTE RESIDENT COUNT FOR THE HOSPITAL'S MOST RECENTLY COMPLETED COST REPORTING PERIOD HOSPITAL DATA For CHGME FI Use Only
1996 CAP YEAR §422 of the MMA MCR DATA FI DATA
4.01 Inclusive dates of the subject cost reporting period (From)


(To)
4.02 Status of MCR


4.03 Unweighted resident FTE count for allopathic and osteopathic programs (from the cap year) 0.00
0.00 0.00
4.04 Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap) 0.00
0.00 0.00
4.05 Adjustment (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs 0.00 0.00 0.00
4.05a Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to §422 of the MMA 0.00
0.00 0.00
4.06 FTE adjusted cap 0.00 0.00 0.00 0.00
4.07 Unweighted resident FTE count for allopathic and osteopathic programs. 0.00 0.00 0.00 0.00
4.08 Enter the lesser of lines 4.06 and 4.07 0.00 0.00 0.00 0.00
4.09 Unweighted resident FTE count for allopathic and osteopathic residents in their initial residency period 0.00 0.00 0.00 0.00
4.10 Unweighted resident FTE count for allopathic and osteopathic residents beyond their initial residency period 0.00 0.00 0.00 0.00
4.11 Weighted resident FTE count for allopathic an osteopathic residents beyond their initial residency period 0.00 0.00 0.00 0.00
4.12 Weighted resident FTE count for allopathic osteopathic programs 0.00 0.00 0.00 0.00
4.13 Weighted resident FTE count for allopathic and osteopathic programs following application of the resident FTE adjusted cap 0.00 0.00 0.00 0.00
4.14 Unweighted resident FTE count for dental and podiatric programs 0.00
0.00 0.00
4.15 Unweighted resident FTE count for dental and podiatric residents in their initial residency period 0.00 0.00 0.00
4.16 Unweighted resident FTE count for dental and podiatric resident beyond their initial residency period 0.00 0.00 0.00
4.17 Weighted resident FTE count for dental and podiatric residents beyond their initial residency period 0.00 0.00 0.00
4.18 Weighted resident FTE count for dental and podiatric programs 0.00 0.00 0.00
4.19 Total unweighted resident FTE count 0.00 0.00 0.00 0.00
4.20 Total weighted resident FTE count 0.00 0.00 0.00 0.00









HRSA 99-1 Page 2 of 4





Created in MS Excel 7.0
(Rev. 03-2007)








Sheet 4: HRSA 99-1 Page 3 of 4

Department of Health and Human Services





OMB N0. 0915-0247
Health Resources and Services Administration




Expiration Date: 03/31/2010


















Children's Hospitals Graduate Medical Education Payment Program Determination of Weighted and Unweighted Resident FTE Counts
Name of Applicant: 0
City: 0 State: 0 Zip Code: 0
Medicare Provider Number: 0
Fiscal Year in which applying for funding: FFY
Type of Application (check box to the left) ____Initial Application
______Reconciliation Application
Section 5 DETERMINATION OF FTE RESIDENT COUNT FOR THE HOSPITAL'S PRIOR COST REPORTING PERIOD HOSPITAL DATA For CHGME FI Use Only
1996 Cap Year MCR DATA FI DATA
5.01 Inclusive dates of the subject cost reporting period (From)


(To)
5.02 Status of MCR


5.03 Unweighted resident FTE count for allopathic and osteopathic programs 0.00 0.00 0.00
5.04 Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap) 0.00 0.00 0.00
5.05 Adjustment (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs 0.00 0.00 0.00
5.05a Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to §422 of the MMA
0.00 0.00
5.06 FTE adjusted cap 0.00 0.00 0.00
5.07 Unweighted resident FTE count for allopathic and osteopathic programs. 0.00 0.00 0.00
5.08 Enter the lesser of lines 4.06 and 4.07 0.00 0.00 0.00
5.09 Unweighted resident FTE count for allopathic and osteopathic residents in their initial residency period 0.00 0.00 0.00
5.10 Unweighted resident FTE count for allopathic and osteopathic residents beyond their initial residency period 0.00 0.00 0.00
5.11 Weighted resident FTE count for allopathic an osteopathic residents beyond their initial residency period 0.00 0.00 0.00
5.12 Weighted resident FTE count for allopathic osteopathic programs 0.00 0.00 0.00
5.13 Weighted resident FTE count for allopathic and osteopathic programs following application of the resident FTE adjusted cap 0.00 0.00 0.00
5.14 Unweighted resident FTE count for dental and podiatric programs 0.00 0.00 0.00
5.15 Unweighted resident FTE count for dental and podiatric residents in their initial residency period 0.00 0.00 0.00
5.16 Unweighted resident FTE count for dental and podiatric resident beyond their initial residency period 0.00 0.00 0.00
5.17 Weighted resident FTE count for dental and podiatric residents beyond their initial residency period 0.00 0.00 0.00
5.18 Weighted resident FTE count for dental and podiatric programs 0.00 0.00 0.00
5.19 Total unweighted resident FTE count 0.00 0.00 0.00
5.20 Total weighted resident FTE count 0.00 0.00 0.00



























HRSA 99-1 Page 3 of 4





Created in MS Excel 7.0
(Rev. 03-2007)








Sheet 5: HRSA 99-1 Page 4 of 4

Department of Health and Human Services





OMB N0. 0915-0247
Health Resources and Services Administration




Expiration Date: 03/31/2010


















Children's Hospitals Graduate Medical Education Payment Program Determination of Weighted and Unweighted Resident FTE Counts
Name of Applicant: 0
City: 0 State: 0 Zip Code: 0
Medicare Provider Number: 0
Fiscal Year in which applying for funding: FFY
Type of Application (check box to the left) ____Initial Application
______Reconciliation Application
Section 6 DETERMINATION OF FTE RESIDENT COUNT FOR THE HOSPITAL'S PENULTIMATE COST REPORTING PERIOD HOSPITAL DATA For CHGME FI Use Only
1996 Cap Year MCR DATA FI DATA
6.01 Inclusive dates of the subject cost reporting period (From)


(To)
6.02 Status of MCR


6.03 Unweighted resident FTE count for allopathic and osteopathic programs 0.00 0.00 0.00
6.04 Unweighted resident FTE count for allopathic and osteopathic programs which meet the criteria for an add-on (to the cap) 0.00 0.00 0.00
6.05 Adjustment (to the cap) for the Unweighted resident FTE count for allopathic and osteopathic programs for affiliated programs 0.00 0.00 0.00
6.05a Reduction (to the cap) for the unweighted resident FTE count for allopathic and osteopathic programs due to §422 of the MMA 0.00 0.00 0.00
6.06 FTE adjusted cap 0.00 0.00 0.00
6.07 Unweighted resident FTE count for allopathic and osteopathic programs. 0.00 0.00 0.00
6.08 Enter the lesser of lines 4.06 and 4.07 0.00 0.00 0.00
6.09 Unweighted resident FTE count for allopathic and osteopathic residents in their initial residency period 0.00 0.00 0.00
6.10 Unweighted resident FTE count for allopathic and osteopathic residents beyond their initial residency period 0.00 0.00 0.00
6.11 Weighted resident FTE count for allopathic an osteopathic residents beyond their initial residency period 0.00 0.00 0.00
6.12 Weighted resident FTE count for allopathic osteopathic programs 0.00 0.00 0.00
6.13 Weighted resident FTE count for allopathic and osteopathic programs following application of the resident FTE adjusted cap 0.00 0.00 0.00
6.14 Unweighted resident FTE count for dental and podiatric programs 0.00 0.00 0.00
6.15 Unweighted resident FTE count for dental and podiatric residents in their initial residency period 0.00 0.00 0.00
6.16 Unweighted resident FTE count for dental and podiatric resident beyond their initial residency period 0.00 0.00 0.00
6.17 Weighted resident FTE count for dental and podiatric residents beyond their initial residency period 0.00 0.00 0.00
6.18 Weighted resident FTE count for dental and podiatric programs 0.00 0.00 0.00
6.19 Total unweighted resident FTE count 0.00 0.00 0.00
6.20 Total weighted resident FTE count 0.00 0.00 0.00













































HRSA 99-1 Page 4 of 4





Created in MS Excel 7.0
(Rev. 03-2007)








Sheet 6: HRSA 99-2 Cover Page

Department of Health and Human Services






OMB N0. 0915-0247
Health Resources and Services Administration





Expiration Date: 03/31/2010














CHILDREN’S HOSPITALS GRADUATE MEDICAL EDUCATION PAYMENT PROGRAM

APPLICATION FORM HRSA 99-2


















































































Public Burden Statement





An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915 0247. Public reporting burden for the applicant for this collection of information is estimated to average 69 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14 33, Rockville, Maryland, 20857.




























Sheet 7: HRSA 99-2 Page 1 of 1

Department of Health and Human Services





OMB N0. 0915-0247
Health Resources and Services Administration




Expiration Date: 03/31/2010









Children's Hospitals Graduate Medical Education Payment Program Determination of Indirect Medical Education Data Related to the Teaching of Residents









Name of Applicant: 0
City 0 State 0 Zip Code: 0
Medicare Provider Number 0
Fiscal Year in which Applying for Funding: FFY
Type of Application (check box to the left) ____Initial Application
______Reconciliation Application
Inpatient Data for the Current Medicare Cost Report (MCR) Period
1.01 Inclusive dates of the current MCR period From:
To:
1.02 Number of Inpatient Days
1.03 Number of Inpatient Discharges
1.04 Case Mix Index (CMI)

Hospitals that elect not to submit a CMI are required to initial the box to the left acknowledging their ineligibility for IME payments. The initials to the left must be consistent with the signature on HRSA 99-3.
IRB Ratio for the Current MCR Period
1.05 3-year adjusted unweighted resident FTE rolling average for the current MCR period 0.00
1.06 Bed count for the current MCR period 0
1.07 IRB ratio for the current MCR period 0.000000
IRB Ratio for the Previous MCR Period
1.08 Inclusive dates of the previous MCR period From:
To:
1.09 Unweighted resident FTE count for the previous MCR period 0.00
1.10 Bed count for previous MCR period 0.00
1.11 IRB ratio for the previous MCR period 0.000000
IRB Cap
1.12 IRB Cap (lesser of 1.07 or 1.11) 0.000000
§422 of the MMA IRB Ratio for the Current MCR Period
1.13 §422 of the MMA unweighted resident FTE count for the current MCR period 0.00
1.14 Bed count for the current MCR period 0.00
1.15 §422 of the MMA IRB ratio for the current MCR period 0.000000
Outpatient Data
1.16 Number of Ambulatory Surgery Visits 0.00
1.17 Number of Radiology Visits 0.00
1.18 Number of Urgent Care Visits 0.00
1.19 Number of Emergency Department Visits 0.00
1.20 Number of Clinic Visits 0.00



























HRSA 99-2 Page 1 of 1





Created in MS Excel 7.0
(Rev. 03-2007)







File Typeapplication/vnd.ms-excel
AuthorHRSA/BCBSA
File Modified2008-07-16
File Created2003-10-09

© 2024 OMB.report | Privacy Policy