Hospitals and Health Care Complex Cost Report (CMS-2552-96)

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Overview

H
H1I
H1II
H2I
H2II
H3
H4
H5

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Sheet 1: H

DRAFT					FORM CMS-2552-10							4090 (Cont.)
ANALYSIS OF PROVIDER-BASED							PROVIDER NO.: __________		PERIOD:		WORKSHEET H
HOME HEALTH AGENCY COSTS									FROM __________
							HHA NO.: ________________		TO _____________
				TRANSPOR-	CONTRACTED/				RECLASSIFIED		NET
		SALARIES	EMPLOYEE	TATION	PURCHASED		TOTAL		TRIAL		EXPENSES FOR
	COST CENTER DESCRIPTIONS		BENEFITS	(see	SERVICES		(sum of cols.	RECLASSIFI-	BALANCE		ALLOCATION
	(omit cents)			instructions)		OTHER COSTS	1 thru 5)	CATIONS	(col. 6 + col. 7)	ADJUSTMENTS	(col. 8 + col. 9)
		1	2	3	4	5	6	7	8	9	10
	GENERAL SERVICE COST CENTERS
1	Capital Related-Bldgs. and Fixtures											1
2	Capital Related-Movable Equipment											2
3	Plant Operation & Maintenance											3
4	Transportation (see instructions)											4
5	Administrative and General											5
	HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care											6
7	Physical Therapy											7
8	Occupational Therapy											8
9	Speech Pathology											9
10	Medical Social Services											10
11	Home Health Aide											11
12	Supplies (see instructions)											12
13	Drugs											13
14	DME											14
	HHA NONREIMBURSABLE SERVICES
15	Home Dialysis Aide Services											15
16	Respiratory Therapy											16
17	Private Duty Nursing											17
18	Clinic											18
19	Health Promotion Activities											19
20	Day Care Program											20
21	Home Delivered Meals Program											21
22	Homemaker Service											22
23	All Others											23
24	Total (sum of lines 1-23)											24
Column, 6 line 24 should agree with the Worksheet A, column 3, line 101, or subscript as applicable.
FORM HCFA-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN HCFA PUB. 15-II, SECTION 4041)
Rev. 1												40-605

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Sheet 2: H1I

4090 (Cont.)			FORM CMS-2552-10							DRAFT
COST ALLOCATION - HHA GENERAL SERVICE COST					PROVIDER NO.: ___________		PERIOD:		WORKSHEET H-1
							FROM ________________		PART I
					HHA NO.: ________________		TO ___________________
		NET EXPENSES	CAPITAL
		FOR COST	RELATED COSTS
		ALLOCATION			PLANT			ADMINIS-
		(from Wkst.	BLDGS. &	MOVABLE	OPERATION &	TRANS-	SUBTOTAL	TRATIVE	TOTAL
		H, col. 10)	FIXTURES	EQUIPMENT	MAINTENANCE	PORTATION	(cols. 0-4)	& GENERAL	(cols. 4a + 5)
		0	1	2	3	4	4a	5	6
	GENERAL SERVICE COST CENTERS
1	Capital Related-Bldgs. and Fixtures									1
2	Capital Related-Movable Equipment									2
3	Plant Operation & Maintenance									3
4	Transportation (see instructions)									4
5	Administrative and General									5
	HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care									6
7	Physical Therapy									7
8	Occupational Therapy									8
9	Speech Pathology									9
10	Medical Social Services									10
11	Home Health Aide									11
12	Supplies (see instructions)									12
13	Drugs									13
14	DME									14
	HHA NONREIMBURSABLE SERVICES
15	Home Dialysis Aide Services									15
16	Respiratory Therapy									16
17	Private Duty Nursing									17
18	Clinic									18
19	Health Promotion Activities									19
20	Day Care Program									20
21	Home Delivered Meals Program									21
22	Homemaker Service									22
23	All Others									23
24	Totals (sum of lines 1-23)									24
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4042)
40-606										Rev. 1

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Sheet 3: H1II

DRAFT		FORM CMS-2552-10							4090 (Cont.)
COST ALLOCATION - HHA STATISTICAL BASIS				PROVIDER NO.: __________		PERIOD:		WORKSHEET H-1,
						FROM _________________		PART II
				HHA NO.: ________________		TO ___________________
			CAPITAL
			RELATED COSTS		PLANT			ADMINIS-
			BLDGS. &	MOVABLE	OPERATION &			TRATIVE
			FIXTURES	EQUIPMENT	MAINTENANCE	TRANS-		& GENERAL
			(SQUARE	(DOLLAR	(SQUARE	PORTATION	RECONCIL-	(ACCUM.
			FEET)	VALUE)	FEET)	(MILEAGE)	IATION	COST)
			1	2	3	4	5a	5
	GENERAL SERVICE COST CENTERS
1	Capital Related-Bldgs. and Fixtures								1
2	Capital Related-Movable Equipment								2
3	Plant Operation & Maintenance								3
4	Transportation (see instructions)								4
5	Administrative and General								5
	HHA REIMBURSABLE SERVICES
6	Skilled Nursing Care								6
7	Physical Therapy								7
8	Occupational Therapy								8
9	Speech Pathology								9
10	Medical Social Services								10
11	Home Health Aide								11
12	Supplies (see instructions)								12
13	Drugs								13
14	DME								14
	HHA NONREIMBURSABLE SERVICES
15	Home Dialysis Aide Services								15
16	Respiratory Therapy								16
17	Private Duty Nursing								17
18	Clinic								18
19	Health Promotion Activities								19
20	Day Care Program								20
21	Home Delivered Meals Program								21
22	Homemaker Service								22
23	All Others								23
24	Total (sum of lines 1-23)								24
25	Cost To Be Allocated (per Worksheet H-1, Part I)								25
26	Unit Cost Multiplier								26
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4043)
Rev. 1									40-607

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Sheet 4: H2I

4090 (Cont.)						FORM CMS-2552-10								DRAFT	DRAFT				FORM CMS-2552-10									4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10							DRAFT
ALLOCATION OF GENERAL SERVICE							PROVIDER NO.: ______________			PERIOD:		WORKSHEET H-2,			ALLOCATION OF GENERAL SERVICE						PROVIDER NO.: ______________			PERIOD:		WORKSHEET H-2,			ALLOCATION OF GENERAL SERVICE				PROVIDER NO.: ______________			PERIOD:		WORKSHEET H-2,
COSTS TO HHA COST CENTERS							HHA NO.: _____________			FROM__________________		PART I			COSTS TO HHA COST CENTERS						HHA NO.: _____________			FROM__________________		PART I (CONT.)			COSTS TO HHA COST CENTERS				HHA NO.: _____________			FROM ______________		PART I (CONT.)
										TO ___________________														TO ___________________												TO _________________
						CAPITAL																														INTERN &
				From	HHA	RELATED COSTS																					NON-									RESIDENT		ALLOCATED
	HHA COST CENTER			Wkst. H-1	TRIAL					ADMINIS-	MAIN-		LAUNDRY			HHA COST CENTER				MAIN-	NURSING	CENTRAL		MEDICAL		OTHER	PHYSICIAN			HHA COST CENTER		INTERNS & RESIDENTS		PARAMEDICAL	SUBTOTAL	COST & POST		HHA
	(omit cents)			Part I,	BALANCE	BLDGS. &	MOVABLE	EMPLOYEE	SUBTOTAL	TRATIVE &	TENANCE &	OPERATION	& LINEN			(omit cents)	HOUSE			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &	SOCIAL	GENERAL	ANES-			(omit cents)	NURSING	SALARY AND	PROGRAM	EDUCATION	(sum of cols.	STEPDOWN	SUBTOTAL	A&G (see	TOTAL
				col. 6,	(1)	FIXTURES	EQUIPMENT	BENEFITS	(cols. 0-4)	GENERAL	REPAIRS	OF PLANT	SERVICE				KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY	SERVICE	SERVICE	THETISTS				SCHOOL	FRINGES	COSTS	(SPECIFY)	4a-23)	ADJUSTMENTS	(cols. 23 ± 24)	Part II)	HHA COSTS
				line	0	1	2	4	4A	5	6	7	8				9	10	11	12	13	14	15	16	17	18	19				20	21	22	23	24	25	26	27	28
1	Administrative and General			5										1	1	Administrative and General												1	1	Administrative and General										1
2	Skilled Nursing Care			6										2	2	Skilled Nursing Care												2	2	Skilled Nursing Care										2
3	Physical Therapy			7										3	3	Physical Therapy												3	3	Physical Therapy										3
4	Occupational Therapy			8										4	4	Occupational Therapy												4	4	Occupational Therapy										4
5	Speech Pathology			9										5	5	Speech Pathology												5	5	Speech Pathology										5
6	Medical Social Services			10										6	6	Medical Social Services												6	6	Medical Social Services										6
7	Home Health Aide			11										7	7	Home Health Aide												7	7	Home Health Aide										7
8	Supplies			12										8	8	Supplies												8	8	Supplies										8
9	Drugs			13										9	9	Drugs												9	9	Drugs										9
10	DME			14										10	10	DME												10	10	DME										10
11	Home Dialysis Aide Services			15										11	11	Home Dialysis Aide Services												11	11	Home Dialysis Aide Services										11
12	Respiratory Therapy			16										12	12	Respiratory Therapy												12	12	Respiratory Therapy										12
13	Private Duty Nursing			17										13	13	Private Duty Nursing												13	13	Private Duty Nursing										13
14	Clinic			18										14	14	Clinic												14	14	Clinic										14
15	Health Promotion Activities			19										15	15	Health Promotion Activities												15	15	Health Promotion Activities										15
16	Day Care Program			20										16	16	Day Care Program												16	16	Day Care Program										16
17	Home Delivered Meals Program			21										17	17	Home Delivered Meals Program												17	17	Home Delivered Meals Program										17
18	Homemaker Service			22										18	18	Homemaker Service												18	18	Homemaker Service										18
19	All Others			23										19	19	All Others												19	19	All Others										19
20	Totals (sum of lines 1-19) (2)													20	20	Totals (sum of lines 1-19) (2)												20	20	Totals (sum of lines 1-19) (2)										20
21	Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20													21	21	Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20												21	21	Unit Cost Multiplier: column 26, line 1 divided by the sum of column 26, line 20										21
	minus column 26, line 1, rounded to 6 decimal places.															minus column 26, line 1, rounded to 6 decimal places.														minus column 26, line 1, rounded to 6 decimal places.
(1) Column 0, line 20 must agree with Wkst. A, column 7, line 101.															(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.														(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.
(2) Columns 0 through 26, line 20 must agree with the corresponding columns of Wkst. B, Part I, line 101.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4043.1)															FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4043.1)														FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4043.1)
40-608														Rev. 1	Rev. 1													40-609	40-610											Rev. 1

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Sheet 5: H2II

DRAFT			FORM CMS-2552-10							4090 (Cont.)	4090 (Cont.)				FORM CMS-2552-10							DRAFT	DRAFT		FORM CMS-2552-10							4090 (Cont.)
ALLOCATION OF GENERAL SERVICE					PROVIDER NO.: ___________		PERIOD:		WORKSHEET H-2,		ALLOCATION OF GENERAL SERVICE						PROVIDER NO.: ______________		PERIOD:		WORKSHEET H-2,		ALLOCATION OF GENERAL SERVICE				PROVIDER NO.: __________		PERIOD:		WORKSHEET H-2,
COSTS TO HHA COST CENTERS					HHA NO.: _____________		FROM__________________		PART II		COSTS TO HHA COST CENTERS						HHA NO.: _____________		FROM__________________		PART II (CONT.)		COSTS TO HHA COST CENTERS				HHA NO.: _____________		FROM__________________		PART II (CONT.)
STATISTICAL BASIS							TO ___________________				STATISTICAL BASIS								TO ___________________				STATISTICAL BASIS						TO ___________________
			CAPITAL																								NON-				PARA-
			RELATED COST				ADMINIS-	MAIN-					LAUNDRY				MAIN-	NURSING	CENTRAL		MEDICAL						PHYSICIAN		INTERNS & RESIDENTS		MEDICAL
			BLDGS. &	MOVABLE	EMPLOYEE		TRATIVE &	TENANCE &	OPERATION				& LINEN	HOUSE-			TENANCE OF	ADMINIS-	SERVICES &		RECORDS &				SOCIAL	OTHER	ANES-	NURSING	SALARY &	PROGRAM	EDUCATION
	HHA COST CENTER		FIXTURES	EQUIPMENT	BENEFITS		GENERAL	REPAIRS	OF PLANT			HHA COST CENTER	SERVICE	KEEPING	DIETARY	CAFETERIA	PERSONNEL	TRATION	SUPPLY	PHARMACY	LIBRARY			HHA COST CENTER	SERVICE	GENERAL	THETISTS	SCHOOL	FRINGES	COSTS	(SPECIFY)
			(SQUARE	(DOLLAR	(GROSS	RECONCIL-	(ACCUM.	(SQUARE	(SQUARE				(POUNDS OF	(HOURS OF	(MEALS	(MEALS	(NUMBER	(DIRECT	(COSTED	(COSTED	(TIME				(TIME	SERVICE	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED	(ASSIGNED
			FEET)	VALUE)	SALARIES)	IATION	COST)	FEET)	FEET)				LAUNDRY)	SERVICE)	SERVED)	SERVED)	HOUSED)	NURS. HRS)	REQUIS.)	REQUIS.)	SPENT)				SPENT)	(SPECIFY)	TIME)	TIME)	TIME)	TIME)	TIME)
			1	2	4	4A	5	6	7				8	9	10	11	12	13	14	15	16				17	18	19	20	21	22	23
1	Administrative and General									1	1	Administrative and General										1	1	Administrative and General								1
2	Skilled Nursing Care									2	2	Skilled Nursing Care										2	2	Skilled Nursing Care								2
3	Physical Therapy									3	3	Physical Therapy										3	3	Physical Therapy								3
4	Occupational Therapy									4	4	Occupational Therapy										4	4	Occupational Therapy								4
5	Speech Pathology									5	5	Speech Pathology										5	5	Speech Pathology								5
6	Medical Social Services									6	6	Medical Social Services										6	6	Medical Social Services								6
7	Home Health Aide									7	7	Home Health Aide										7	7	Home Health Aide								7
8	Supplies									8	8	Supplies										8	8	Supplies								8
9	Drugs									9	9	Drugs										9	9	Drugs								9
10	DME									10	10	DME										10	10	DME								10
11	Home Dialysis Aide Services									11	11	Home Dialysis Aide Services										11	11	Home Dialysis Aide Services								11
12	Respiratory Therapy									12	12	Respiratory Therapy										12	12	Respiratory Therapy								12
13	Private Duty Nursing									13	13	Private Duty Nursing										13	13	Private Duty Nursing								13
14	Clinic									14	14	Clinic										14	14	Clinic								14
15	Health Promotion Activities									15	15	Health Promotion Activities										15	15	Health Promotion Activities								15
16	Day Care Program									16	16	Day Care Program										16	16	Day Care Program								16
17	Home Delivered Meals Program									17	17	Home Delivered Meals Program										17	17	Home Delivered Meals Program								17
18	Homemaker Service									18	18	Homemaker Service										18	18	Homemaker Service								18
19	All Others									19	19	All Others										19	19	All Others								19
20	Totals (sum of lines 1-19)									20	20	Totals (sum of lines 1-19)										20	20	Totals (sum of lines 1-19)								20
21	Total cost to be allocated									21	21	Total cost to be allocated										21	21	Total cost to be allocated								21
22	Unit Cost Multiplier									22	22	Unit Cost Multiplier										22	22	Unit Cost Multiplier								22
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4043.2)											FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4043.2)												FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4043.2)
Rev. 1										40-611	40-612											Rev. 1	Rev. 1									40-613

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Sheet 6: H3

4090 (Cont.)

FORM CMS-2552-10

DRAFT

APPORTIONMENT OF PATIENT SERVICE COSTS

PROVIDER NO.:_____________

PERIOD:

WORKSHEET H-3,

FROM ______________

Part I

HHA NO.:________________

TO ________________

Check applicable box

[ ] Title V [ ] Title XVIII [ ] Title XIX

PART I - COMPUTATION OF LESSER OF AGGREGATE PROGRAM COST, AGGREGATE OF THE PROGRAM LIMITATION COST, OR BENEFICIARY COST LIMITATION

Cost Per Visit Computation

Program Visits

Cost of Services

From,

Facility

Shared

Average

Part B

Part B

Wkst.

Costs

Ancillary

Total

Cost

Not

Not

Total

H-2,

(from

Costs

HHA

Per Visit

Subject to

Subject to

Subject to

Subject to

Program Cost

Patient Services

Part I,

Wkst. H-2,

(from

Costs

Total

(col. 3

Deductibles

Deductibles

Deductibles

Deductibles

(sum of

col. 28,

Part I)

Part II)

(cols. 1 + 2)

Visits

÷ col. 4)

Part A

& Coinsurance

& Coinsurance

Part A

& Coinsurance

& Coinsurance

cols. 9-10)

line

1

2

3

4

5

6

7

8

9

10

11

12

1

Skilled Nursing Care

2

1

2

Physical Therapy

3

2

3

Occupational Therapy

4

3

4

Speech Pathology

5

4

5

Medical Social Services

6

5

6

Home Health Aide

7

6

7

Total (sum of lines 1-6)

7

Limitation Cost Computation

Program Visits

Part B

Not Subject to

Subject to

Patient Services

CBSA

Deductibles

Deductibles

No. (1)

Part A

& Coinsurance

& Coinsurance

1

2

3

4

8

Skilled Nursing Care

8

9

Physical Therapy

9

10

Occupational Therapy

10

11

Speech Pathology

11

12

Medical Social Services

12

13

Home Health Aide

13

14

Total (sum of lines 8-13)

14

Supplies and Drugs Cost Computations

Program Covered Charges

Cost of Services

Facility

Shared

Part B

Part B

From

Costs

Ancillary

Total

Total

Not

Not

Wkst. H-2

(from

Costs

HHA

Charges

Ratio

Subject to

Subject to

Subject to

Subject to

Other Patient Services

Part I,

Wkst. H-2,

(from

Costs

(from HHA

(col. 3

Deductibles

Deductibles

Deductibles

Deductibles

col. 28,

Part I)

Part II)

(cols. 1 + 2)

Record)

÷ col. 4)

Part A

& Coinsurance

& Coinsurance

Part A

& Coinsurance

& Coinsurance

line

1

2

3

4

5

6

7

8

9

10

11

15

Cost of Medical Supplies

8

15

16

Cost of Drugs

9

16

PART II - APPORTIONMENT OF COST OF HHA SERVICES FURNISHED BY SHARED HOSPITAL DEPARTMENTS

Total

Cost

HHA Charges

HHA Shared

Transfer to

From Wkst. C,

to Charge

(from provider

Ancillary Costs

Part I

Part I, col. 9,

Ratio

records)

(col. 1 x col. 2)

as Indicated

line

1

2

3

4

1

Physical Therapy

63

col. 2, line 2

1

2

Occupational Therapy

64

col. 2, line 3

2

3

Speech Pathology

65

col. 2, line 4

3

4

Cost of Medical Supplies

68

col. 2, line 15

4

5

Cost of Drugs

70

col. 2, line 16

5

FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4044)

40-614

Rev. 1

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Sheet 7: H4

DRAFT		FORM CMS-2552-10				4090 (Cont.)
CALCULATION OF HHA REIMBURSEMENT			PROVIDER NO.:	PERIOD:	WORKSHEET H-4,
SETTLEMENT			______________	FROM___________	Parts I & II
			HHA NO.:	TO______________
			______________
Check Applicable Box		[ ] Title V	[ ] Title XVIII	[ ] Title XIX
PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES
				Part B
				Not Subject to	Subject to
				Deductibles	Deductibles
			Part A	& Coinsurance	& Coinsurance
	Description		1	2	3
	Reasonable Cost of Part A & Part B Services
1	Reasonable cost of services (see instructions)					1
2	Total charges					2
	Customary Charges
3	Amount actually collected from patients liable for payment					3
	for services on a charge basis (from your records)
4	Amount that would have been realized from patients liable					4
	for payment for services on a charge basis had such
	payment been made in accordance with 42 CFR 413.13(b)
5	Ratio of line 3 to line 4 (not to exceed 1.000000)					5
6	Total customary charges (see instructions)					6
7	Excess of total customary charges over total reasonable					7
	cost (complete only if line 6 exceeds line 1)
8	Excess of reasonable cost over customary charges					8
	(complete only if line 1 exceeds line 6)
9	Primary payer amounts					9
PART II - COMPUTATION OF HHA REIMBURSEMENT SETTLEMENT
				Part A Services	Part B Services
	Description			1	2
10	Total reasonable cost (see instructions)					10
11	Total PPS Reimbursement - Full Episodes without Outliers					11
12	Total PPS Reimbursement - Full Episodes with Outliers					12
13	Total PPS Reimbursement - LUPA Episodes					13
14	Total PPS Reimbursement - PEP Episodes					14
15	Total PPS Outlier Reimbursement - Full Episodes with Outliers					15
16	Total PPS Outlier Reimbursement - PEP Episodes					16
17	Total Other Payments					17
18	DME Payments					18
19	Oxygen Payments					19
20	Prosthetic and Orthotic Payments					20
21	Part B deductibles billed to Medicare patients (exclude coinsurance)					21
22	Subtotal (sum of lines 10 thru 20 minus line 21)					22
23	Excess reasonable cost (from line 8)					23
24	Subtotal (line 22 minus line 23)					24
25	Coinsurance billed to program patients (from your records)					25
26	Net cost (line 24 minus line 25)					26
27	Reimbursable bad debts (from your records)					27
28	Reimbursable bad debts for dual eligible beneficiaries (see instructions)					28
29	Total costs - current cost reporting period (line 26 plus line 27)					29
30	Other adjustments (see instructions) (specify)					30
31	Subtotal (line 29 plus/minus line 30)					31
32	Interim payments (see instructions)					32
33	Tentative settlement (for contractor use only)					33
34	Balance due provider/program (line 31 minus lines 32 and 33)					34
35	Protested amounts (nonallowable cost report items) in accordance with CMS					35
	Pub. 15-II, section 115.2
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4045.1 - 4045.2)
Rev. 1						40-615

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Sheet 8: H5

4090 (Cont.)						FORM CMS-2552-10						DRAFT
ANALYSIS OF PAYMENTS TO PROVIDER-						PROVIDER NO.:			PERIOD:		WORKSHEET H-5																		{APP4}IALLWAYS~/lp2~q/PCOPB1~Q/pGQ/1
BASED HHAs FOR SERVICES						______________________			FROM _____________
RENDERED TO PROGRAM BENEFICIARIES						HHA NO.:			TO ________________
						______________________
		Description						Part A		Part B
								mm/dd/yyyy	Amount	mm/dd/yyyy	Amount
								1	2	3	4
1	Total interim payments paid to provider											1
2	Interim payments payable on individual bills either submitted or											2
	to be submitted to the intermediary for services rendered in the
	cost reporting period. If none, write "NONE" or enter a zero.
3	List separately each retroactive lump sum						.01					3.01
	adjustment amount based on subsequent revision						.02					3.02
	of the interim rate for the cost reporting period.					Program	.03					3.03
	Also show date of each payment. If none, write					to	.04					3.04
	"NONE" or enter a zero.(1)					Provider	.05					3.05
							.50					3.50
							.51					3.51
						Provider	.52					3.52
						to	.53					3.53
						Program	.54					3.54
	Subtotal (sum of lines 3.01-3.49 minus sum
	of lines 3.50-3.98)						.99					3.99
4	Total interim payments (sum of lines 1, 2, and 3.99)											4
	(transfer to Wkst. H-4, Part II, column as appropriate, line 23)
				TO BE COMPLETED BY INTERMEDIARY
5	List separately each tentative settlement payment					Program	.01					5.01
	after desk review. Also show date of each					to	.02					5.02
	payment. If none, write "NONE" or enter					Provider	.03					5.03
	a zero. (1)					Provider	.50					5.50
						to	.51					5.51
						Program	.52					5.52
	Subtotal (sum of lines 5.01-5.49 minus sum
	of lines 5.50-5.98)						.99					5.99
6	Determine net settlement amount (balance due)					Program
	based on the cost report (see instructions)					to	.01
						Provider						6.01
						Provider
						to	.02
						Program						6.02
7	TOTAL MEDICARE PROGRAM LIABILITY											7
	(see instructions)
8	Name of Contractor					Contractor Number			Date: Month, Day, Year			8
(1) On lines 3, 5, and 6, where an amount is due provider to program, show the amount and date on which the provider
agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4046)
40-616												Rev. 1