DRAFT | FORM CMS-2552-10 | 4090 (Cont.) | ||||||||
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result in all interim | FORM APPROVED | |||||||||
payments made since the beginning of the cost reporting period being deemed overpayments (42 USC 1395g). | OMB NO. 0938-0050 | |||||||||
HOSPITAL AND HOSPITAL HEALTH CARE | PROVIDER NO.: | PERIOD: | WORKSHEET S, | |||||||
COMPLEX COST REPORT CERTIFICATION | FROM _____________ | PARTS I, II & III | ||||||||
AND SETTLEMENT SUMMARY | _____________ | TO ________________ | ||||||||
PART I - COST REPORT STATUS | ||||||||||
Provider use only | [ ] Electronically filed cost report | Date: | Time: | |||||||
[ ] Manually submitted cost report | ||||||||||
[ ] If this is an amended report enter the number of times the provider resubmitted this cost report | ||||||||||
Contractor | [ ] Cost Report Status | If 3 or 4: | Date Received: _________ | |||||||
use only | (1) As Submitted | (3) Settled | [ ] Desk Reviewed | Contractor No._________ | ||||||
(2) Amended | (4) Reopened | [ ] Audited | [ ] First Report Processed by Contractor | |||||||
If 4, number of times reopened [ ] | [ ] Last Report to be Processed by Contractor | |||||||||
PART II - CERTIFICATION | ||||||||||
MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY CRIMINAL, | ||||||||||
CIVIL AND ADMINISTRATIVE ACTION, FINE AND/OR IMPRISONMENT UNDER FEDERAL LAW. FURTHERMORE, IF SERVICES IDENTIFIED IN THIS | ||||||||||
REPORT WERE PROVIDED OR PROCURED THROUGH THE PAYMENT DIRECTLY OR INDIRECTLY OF A KICKBACK OR WERE OTHERWISE | ||||||||||
ILLEGAL, CRIMINAL, CIVIL AND ADMINISTRATIVE ACTION, FINES AND/OR IMPRISONMENT MAY RESULT. | ||||||||||
CERTIFICATION BY OFFICER OR ADMINISTRATOR OF PROVIDER(S) | ||||||||||
I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying electronically filed or manually submitted cost | ||||||||||
report and the Balance Sheet and Statement of Revenue and Expenses prepared by _________________________{Provider Name(s) and Number(s)} | ||||||||||
for the cost reporting period beginning ______________ and ending ______________ and to the best of my knowledge and belief, it is a true, correct | ||||||||||
and complete statement prepared from the books and records of the provider in accordance with applicable instructions, except as noted. I further | ||||||||||
certify that I am familiar with the laws and regulations regarding the provision of health care services identified in this cost report were provided in | ||||||||||
compliance with such laws and regulations. | ||||||||||
(Signed)________________________________________________ | ||||||||||
Officer or Administrator of Provider(s) | ||||||||||
______________________________________________ | ||||||||||
Title | ||||||||||
______________________________________________ | ||||||||||
Date | ||||||||||
PART III - SETTLEMENT SUMMARY | ||||||||||
TITLE XVIII | ||||||||||
TITLE V | PART A | PART B | HIT | TITLE XIX | ||||||
1 | 2 | 3 | 4 | 5 | ||||||
1 | HOSPITAL | 1 | ||||||||
2 | SUBPROVIDER - IPF | 2 | ||||||||
3 | SUBPROVIDER - IRF | 3 | ||||||||
4 | SUBPROVIDER (OTHER) | 4 | ||||||||
5 | SWING BED - SNF | 5 | ||||||||
6 | SWING BED - NF | 6 | ||||||||
7 | SKILLED NURSING FACILITY | 7 | ||||||||
8 | NURSING FACILITY | 8 | ||||||||
9 | HOME HEALTH AGENCY | 9 | ||||||||
10 | HEALTH CLINIC - RHC | 10 | ||||||||
11 | HEALTH CLINIC - FQHC | 11 | ||||||||
OUTPATIENT REHABILITATION | ||||||||||
12 | PROVIDER (Specify) | 12 | ||||||||
200 | TOTAL | 200 | ||||||||
The above amounts represent "due to" or "due from" the applicable program for the element of the above complex indicated. | ||||||||||
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 0938-0050. The time required to complete this information collection is estimated 673 hours per response, including the time to review instructions, | ||||||||||
search existing resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions | ||||||||||
for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Report Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. | ||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4003.1-4003.3) | ||||||||||
Rev. 1 | 40-503 |
4090 (Cont.) | FORM CMS-2552-10 | DRAFT | ||||||||||||||||||||||||||||||||||||||||||
HOSPITAL AND HOSPITAL HEALTH CARE | PROVIDER NO.: | PERIOD: | WORKSHEET S-2 | . | . | |||||||||||||||||||||||||||||||||||||||
COMPLEX IDENTIFICATION DATA | FROM_____________ | Part I | ||||||||||||||||||||||||||||||||||||||||||
______________ | TO________________ | |||||||||||||||||||||||||||||||||||||||||||
Hospital and Hospital Health Care Complex Address: | ||||||||||||||||||||||||||||||||||||||||||||
1 | Street: | P.O. Box: | 1 | |||||||||||||||||||||||||||||||||||||||||
2 | City: | State: | Zip Code: | County: | 2 | |||||||||||||||||||||||||||||||||||||||
Hospital and Hospital-Based Component Identification: | Payment System | |||||||||||||||||||||||||||||||||||||||||||
Provider | CBSA | Provider | Date | (P, T, O, or N) | ||||||||||||||||||||||||||||||||||||||||
Component | Component Name | Number | Number | Type | Certified | V | XVIII | XIX | ||||||||||||||||||||||||||||||||||||
0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | ||||||||||||||||||||||||||||||||||||
3 | Hospital | 3 | ||||||||||||||||||||||||||||||||||||||||||
4 | Subprovider- IPF | 4 | ||||||||||||||||||||||||||||||||||||||||||
5 | Subprovider- IRF | 5 | ||||||||||||||||||||||||||||||||||||||||||
6 | Subprovider- (Other) | 6 | ||||||||||||||||||||||||||||||||||||||||||
7 | Swing Beds-SNF | 7 | ||||||||||||||||||||||||||||||||||||||||||
8 | Swing Beds-NF | 8 | ||||||||||||||||||||||||||||||||||||||||||
9 | Hospital-Based SNF | 9 | ||||||||||||||||||||||||||||||||||||||||||
10 | Hospital-Based NF | 10 | ||||||||||||||||||||||||||||||||||||||||||
11 | Hospital-Based OLTC | 11 | ||||||||||||||||||||||||||||||||||||||||||
12 | Hospital-Based HHA | 12 | ||||||||||||||||||||||||||||||||||||||||||
13 | Separately Certified ASC | 13 | ||||||||||||||||||||||||||||||||||||||||||
14 | Hospital-Based Hospice | 14 | ||||||||||||||||||||||||||||||||||||||||||
15 | Hospital-Based Health Clinic-RHC | 15 | ||||||||||||||||||||||||||||||||||||||||||
16 | Hospital-Based Health Clinic-FQHC | 16 | ||||||||||||||||||||||||||||||||||||||||||
17 | Hospital-Based (CMHC) | 17 | ||||||||||||||||||||||||||||||||||||||||||
18 | Renal Dialysis | 18 | ||||||||||||||||||||||||||||||||||||||||||
19 | Other | 19 | ||||||||||||||||||||||||||||||||||||||||||
20 | Cost Reporting Period (mm/dd/yyyy) | From:_______________ | To: ______________ | 20 | ||||||||||||||||||||||||||||||||||||||||
1 | 2 | |||||||||||||||||||||||||||||||||||||||||||
21 | Type of Control (see instructions) | 21 | ||||||||||||||||||||||||||||||||||||||||||
Inpatient PPS Information | ||||||||||||||||||||||||||||||||||||||||||||
22 | Does your facility qualify and is currently receiving disproportionate share hospital payment in accordance with 42 CFR §412.106, or low income payment in accordance with | 22 | ||||||||||||||||||||||||||||||||||||||||||
42 CFR §412.624 (e)(2)? Enter in column 1, "Y" for yes and "N" for no. Is this facility subject to 42 CFR §412.06 (c )(2) (Pickle amendment hospital?) | ||||||||||||||||||||||||||||||||||||||||||||
Enter in column 2 Y"Y for yes or "N" for no. | ||||||||||||||||||||||||||||||||||||||||||||
23 | Which method is used to determine Medicaid days on Worksheet S-3, Part I column 7? Enter in column 1, 1 if it is based on date of admission, 2 if it is based on census days, | 23 | ||||||||||||||||||||||||||||||||||||||||||
or 3 if it is based on date of discharge. Enter in column 2 "Y" for yes or "N" for no. | ||||||||||||||||||||||||||||||||||||||||||||
In-State | In-State | Out-of State | Out-of State | Medicaid | Other | |||||||||||||||||||||||||||||||||||||||
Medicaid | Medicaid | Medicaid | Medicaid | HMO | Medicaid | |||||||||||||||||||||||||||||||||||||||
If line 22 is "yes", and this provider is an IPPS hospital enter the in-state Medicaid paid days in col. 1, in-state | paid days | eligible days | paid days | eligible days | days | days | ||||||||||||||||||||||||||||||||||||||
Medicaid eligible days in col. 2 out-of-state Medicaid paid days in col. 3, out-of-state Medicaid eligible days | 1 | 2 | 3 | 4 | 5 | 6 | ||||||||||||||||||||||||||||||||||||||
24 | in col. 4, Medicaid HMO days in col. 5, and other Medicaid days in col. 6. | 24 | ||||||||||||||||||||||||||||||||||||||||||
If line 22 is "yes", and this provider is an IRF then, enter the in-state Medicaid paid days in col. 1, in-state | ||||||||||||||||||||||||||||||||||||||||||||
Medicaid eligible days in col. 2, out-of-state Medicaid days in col. 3, out-of state Medicaid eligible days | ||||||||||||||||||||||||||||||||||||||||||||
25 | in col. 4 Medicaid HMO days in col. 5 and other Medicaid days in col. 6. | 25 | ||||||||||||||||||||||||||||||||||||||||||
26 | For standard Geographic classification ( not wage), what is your status at the beginning of the cost reporting period. Enter (1) for urban and (2) for rural. | 26 | ||||||||||||||||||||||||||||||||||||||||||
27 | For standard Geographic classification ( not wage), what is your status at the end of the cost reporting period. Enter (1) for urban and (2) for rural. | 27 | ||||||||||||||||||||||||||||||||||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1) | ||||||||||||||||||||||||||||||||||||||||||||
40-504 | Rev. 1 | |||||||||||||||||||||||||||||||||||||||||||
DRAFT | FORM CMS-2552-10 | 4090 (Cont.) | ||||||||||||||||||||||||||||||||||||||||||
HOSPITAL AND HOSPITAL HEALTH CARE | PROVIDER NO.: | PERIOD: | WORKSHEET S-2 | |||||||||||||||||||||||||||||||||||||||||
COMPLEX IDENTIFICATION DATA | FROM_____________ | Part I (CONT.) | ||||||||||||||||||||||||||||||||||||||||||
______________ | TO________________ | |||||||||||||||||||||||||||||||||||||||||||
If this is a sole community hospital (SCH), enter the number of periods SCH status in effect in the C/R period. | ||||||||||||||||||||||||||||||||||||||||||||
35 | Enter beginning and ending dates of SCH status on line 36. Subscript line 36 for number of periods in excess of one and enter subsequent dates. | 35 | ||||||||||||||||||||||||||||||||||||||||||
36 | Enter the applicable SCH dates: | Beginning:_______________ | Ending: ______________ | 36 | ||||||||||||||||||||||||||||||||||||||||
If you are a Medicare dependent hospital (MDH), enter the number of periods MDH status in effect in this C/R period. | ||||||||||||||||||||||||||||||||||||||||||||
37 | Enter beginning and ending dates of MDH status on line 38. Subscript line 38 for number of periods in excess of one and enter subsequent dates. | 37 | ||||||||||||||||||||||||||||||||||||||||||
38 | MDH period | Beginning:_______________ | Ending: ______________ | 38 | ||||||||||||||||||||||||||||||||||||||||
V | XVIII | XIX | ||||||||||||||||||||||||||||||||||||||||||
Prospective Payment System (PPS)-Capital | 1 | 2 | 3 | |||||||||||||||||||||||||||||||||||||||||
45 | Does your facility qualify and receive Capital payment for disproportionate share in accordance with 42 CFR §412.320? (see instructions) | 45 | ||||||||||||||||||||||||||||||||||||||||||
46 | If you are eligible for the special exceptions payment pursuant to 42 CFR §412.348(g)? If yes, Worksheet L, Part III and L-1, Parts I-III | 46 | ||||||||||||||||||||||||||||||||||||||||||
47 | Is this a new hospital under 42 CFR §412.300 PPS capital? Enter "Y for yes and "N" for no in column 1. | 47 | ||||||||||||||||||||||||||||||||||||||||||
Are you electing full federal payment? Enter "Y" for yes and "N" for no in col. 2 | ||||||||||||||||||||||||||||||||||||||||||||
V | XVIII | XIX | ||||||||||||||||||||||||||||||||||||||||||
Teaching Hospitals | 1 | 2 | 3 | |||||||||||||||||||||||||||||||||||||||||
55 | Is this a teaching hospital? Enter "Y" for yes or "N" for no. | 55 | ||||||||||||||||||||||||||||||||||||||||||
56 | Is this teaching program approved in accordance with CMS Pub. 15-1, chapter 4? | 5 | ||||||||||||||||||||||||||||||||||||||||||
57 | If line 56 is yes, was Medicare participation and approved teaching program status in effect during the first month of the cost reporting period? | 57 | ||||||||||||||||||||||||||||||||||||||||||
If yes, complete Worksheet E-4 . If no, complete Worksheet D, Part III & IV D-2, Parts II if applicable. | ||||||||||||||||||||||||||||||||||||||||||||
58 | As a teaching hospital, did you elect cost reimbursement for physicians' services as defined | 58 | ||||||||||||||||||||||||||||||||||||||||||
in CMS Pub. 15-I, section 2148? If yes, complete Worksheet D-4. | ||||||||||||||||||||||||||||||||||||||||||||
59 | Are you claiming costs on line 100 of Worksheet A? If yes, complete Worksheet D-2, Part I. | 59 | ||||||||||||||||||||||||||||||||||||||||||
60 | Has your facility direct GME FTE cap (column 1) or IME FTE cap (column 2) been reduced under 42 CFR §413.79(c)(3) or42 CFR §412.105(f)(1)(iv)(B)? | 60 | ||||||||||||||||||||||||||||||||||||||||||
Enter "Y" for yes and "N" for no in the applicable columns (see instructions) | ||||||||||||||||||||||||||||||||||||||||||||
61 | Has your facility received additional direct GME FTE resident cap slots or IME FTE residents cap slots under 42 CFR §413.79(c)(4)or 42 CFR §412.105(f)(1)(iv)(C)? | 61 | ||||||||||||||||||||||||||||||||||||||||||
Enter "Y" for yes and "N" for no in the applicable columns (see instructions) | ||||||||||||||||||||||||||||||||||||||||||||
62 | Are you claiming nursing and allied health costs? (see instructions) | 62 | ||||||||||||||||||||||||||||||||||||||||||
Inpatient Psychiatric Facility PPS | ||||||||||||||||||||||||||||||||||||||||||||
70 | Are you an Inpatient Psychiatric Facility (IPF), or are you an IPF Subprovider? Enter in column 1 "Y" for yes and "N" for no. | 70 | ||||||||||||||||||||||||||||||||||||||||||
71 | If line 70 column 1 is Y, does the facility have a teaching program in the most recent cost report filed on or before November 15, 2004? | 71 | ||||||||||||||||||||||||||||||||||||||||||
Enter in column 1 "Y" for yes or "N" for no. Is this facility training residents in a new teaching program in accordance with 42 CFR §412.424 (d)(1)(iii)(D )? | ||||||||||||||||||||||||||||||||||||||||||||
Enter in column 2 "Y" for yes and "N" for no. | ||||||||||||||||||||||||||||||||||||||||||||
If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions). If the current cost reporting period covers the beginning of the fourth year enter 4 in column 3, | ||||||||||||||||||||||||||||||||||||||||||||
or if the subsequent academic years of the new teaching program in existence, enter 5 . (see instructions) | ||||||||||||||||||||||||||||||||||||||||||||
Inpatient Rehabilitation Facility PPS | ||||||||||||||||||||||||||||||||||||||||||||
75 | Are you an Inpatient Rehabilitation Facility (IRF), or do you contain an IRF subprovider? Enter in column 1 "Y" for yes and "N" for no. | 75 | ||||||||||||||||||||||||||||||||||||||||||
76 | If line 70 column 1 is Y, does the facility have a teaching program in the most recent cost reporting period ending on or before November 15, 2004? | 76 | ||||||||||||||||||||||||||||||||||||||||||
Enter in column 1 "Y" for yes or "N" for no. Is the facility training residents in a new teaching programs in accordance with 42 CFR § 412.424 (d)(1)(iii)(2)? | ||||||||||||||||||||||||||||||||||||||||||||
Enter in column 2 "Y" for yes or "N" for no. If column 2 is Y, enter 1, 2 or 3 respectively in column 3. (see instructions). If the current cost reporting period covers | ||||||||||||||||||||||||||||||||||||||||||||
the beginning of the fourth enter 4 in column 3, or if the subsequent academic years of the teaching program in existence, enter 5. (see instructions) | ||||||||||||||||||||||||||||||||||||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1) | ||||||||||||||||||||||||||||||||||||||||||||
Rev. 1 | 40-505 | |||||||||||||||||||||||||||||||||||||||||||
DRAFT | FORM CMS-2552-10 | 4090 (Cont.) | ||||||||||||||||||||||||||||||||||||||||||
HOSPITAL AND HOSPITAL HEALTH CARE | PROVIDER NO.: | PERIOD: | WORKSHEET S-2 | |||||||||||||||||||||||||||||||||||||||||
COMPLEX IDENTIFICATION DATA | FROM_____________ | Part I (CONT.) | ||||||||||||||||||||||||||||||||||||||||||
______________ | TO________________ | |||||||||||||||||||||||||||||||||||||||||||
Long Term Care Hospital PPS | ||||||||||||||||||||||||||||||||||||||||||||
80 | Are you a Long Term Care Hospital (LTCH)? Enter "Y" for yes or "N" for no. | 80 | ||||||||||||||||||||||||||||||||||||||||||
TEFRA Providers | ||||||||||||||||||||||||||||||||||||||||||||
85 | Is this a new hospital under 42 CFR §413.40(f)(1)(i) TEFRA? Enter "Y" for yes, and "N" for no. | 85 | ||||||||||||||||||||||||||||||||||||||||||
86 | Have you established a new Other subprovider (excluded unit) under 42 CFR §413.40(f)(1)(ii)? Enter "Y" for yes, and "N" for no. | 86 | ||||||||||||||||||||||||||||||||||||||||||
V | XIX | |||||||||||||||||||||||||||||||||||||||||||
Title V or XIX Inpatient Services | 1 | 2 | ||||||||||||||||||||||||||||||||||||||||||
90 | Do you have title V and XIX inpatient hospital services? | 90 | ||||||||||||||||||||||||||||||||||||||||||
91 | Is this hospital reimbursed for title V and XIX through the cost report either in full or in part? | 91 | ||||||||||||||||||||||||||||||||||||||||||
92 | Does the title V and XIX program reduce capital following the Medicare methodology? | 92 | ||||||||||||||||||||||||||||||||||||||||||
93 | Do you operate an ICF\MR facility for purposes of title V and XIX? | 94 | ||||||||||||||||||||||||||||||||||||||||||
94 | Does Title XIX reduces Capital Cost? Enter "Y" for yes or "N" for no. | 94 | ||||||||||||||||||||||||||||||||||||||||||
95 | If line 95 is "Y", by what percentage? | 95 | ||||||||||||||||||||||||||||||||||||||||||
96 | Does Title XIX reduces Operating Cost? Enter "Y" for yes or "N" for no. | 96 | ||||||||||||||||||||||||||||||||||||||||||
97 | If line 97 is "Y", by what percentage? | 97 | ||||||||||||||||||||||||||||||||||||||||||
Rural Providers | ||||||||||||||||||||||||||||||||||||||||||||
105 | Does this hospital qualify as a Critical Access Hospital (CAH)? | 105 | ||||||||||||||||||||||||||||||||||||||||||
106 | If this facility qualifies as an CAH, has it elected the all-inclusive method of payment for outpatient services? (see instructions) | 106 | ||||||||||||||||||||||||||||||||||||||||||
107 | If this facility qualifies as a CAH, is it eligible for cost reimbursement for I &R training programs? Enter "Y" for yes and "N" for no. If yes, the GME elimination would not be on | 107 | ||||||||||||||||||||||||||||||||||||||||||
Worksheet B, Part I, column 26 and the program would be cost reimbursed. If yes complete Worksheet D-2, Part II. | ||||||||||||||||||||||||||||||||||||||||||||
If this facility is a CAH, do I&Rs in an approved medical education program train in the CAH's excluded IPF and/or IRF unit? Enter "Y" for yes or "N" for no in column 2. (see inst.) | ||||||||||||||||||||||||||||||||||||||||||||
108 | Is this a rural hospital qualifying for an exception to the CRNA fee schedule? See 42 CFR §412.113(c). | 108 | ||||||||||||||||||||||||||||||||||||||||||
Physical | Occupational | Speech | Respiratory | |||||||||||||||||||||||||||||||||||||||||
If this hospital qualifies as a CAH or a cost provider, are therapy services provided by outside supplier? Enter "Y" for yes, or "N" for no for the type of | ||||||||||||||||||||||||||||||||||||||||||||
109 | therapy as follow: physical therapy in column 1, occupational therapy in column 2, speech therapy in column 3 and respiratory therapy in column 4. | 109 | ||||||||||||||||||||||||||||||||||||||||||
Miscellaneous Cost Reporting Information | ||||||||||||||||||||||||||||||||||||||||||||
115 | Is this an all-inclusive provider? If yes, enter the method used (A, B, or E only) in column 2. | 115 | ||||||||||||||||||||||||||||||||||||||||||
116 | Are you classified as a referral center? | 116 | ||||||||||||||||||||||||||||||||||||||||||
117 | Are you legally-required to carry malpractice insurance? | 117 | ||||||||||||||||||||||||||||||||||||||||||
118 | Is the malpractice a claims-made or occurrence policy? If the policy is claims made enter 1. If the policy is occurrence, enter 2. | 118 | ||||||||||||||||||||||||||||||||||||||||||
119 | What is the liability limit for the malpractice insurance policy? | 119 | ||||||||||||||||||||||||||||||||||||||||||
Enter in column 1 the monetary limit per lawsuit. Enter in column 2 the monetary limit per policy year. | ||||||||||||||||||||||||||||||||||||||||||||
Is this a SCH or EACH that qualifies for the Outpatient Hold Harmless provision in PPACA §3121?Enter in column 1 "Y" for yes or "N" for no. | ||||||||||||||||||||||||||||||||||||||||||||
120 | Is this a rural hospital with <100 beds which qualifies for the Outpatient Hold Harmless provision in PPACA §3221?. Enter in column 2 "Y" for yes or "N" for no. | 120 | ||||||||||||||||||||||||||||||||||||||||||
Transplant Center Information | ||||||||||||||||||||||||||||||||||||||||||||
125 | Does this facility operate a transplant center? If yes, enter certification date(s) (mm/dd/yyyy) below. | 125 | ||||||||||||||||||||||||||||||||||||||||||
126 | If this is a Medicare certified kidney transplant center, enter the certification date in column 1 and termination date if applicable in column 2. | 126 | ||||||||||||||||||||||||||||||||||||||||||
127 | If this is a Medicare certified heart transplant center, enter the certification date in column 1 and termination date if applicable in column 2. | 127 | ||||||||||||||||||||||||||||||||||||||||||
128 | If this is a Medicare certified liver transplant center, enter the certification date in column 1 and termination date if applicable in column 2. | 128 | ||||||||||||||||||||||||||||||||||||||||||
129 | If this is a Medicare certified lung transplant center, enter the certification date in column 1 and termination date if applicable in column 2. | 129 | ||||||||||||||||||||||||||||||||||||||||||
130 | If this is a Medicare certified pancreas transplant center, enter the certification date in column 1 and termination date if applicable in column 2. | 130 | ||||||||||||||||||||||||||||||||||||||||||
131 | If this is a Medicare certified intestinal transplant center, enter the certification date in column 1 and termination if applicable in column 2. | 131 | ||||||||||||||||||||||||||||||||||||||||||
132 | If this is a Medicare certified islet transplant center, enter the certification date in column 1 and termination date if applicable in column 2. | 132 | ||||||||||||||||||||||||||||||||||||||||||
133 | If this is a Medicare certified other transplant center, enter the certification date in column 1 and termination date if applicable in column 2. | 133 | ||||||||||||||||||||||||||||||||||||||||||
134 | If this is an organ procurement organization (OPO), enter the OPO number in column 1 and termination date if applicable in column 2. | 134 | ||||||||||||||||||||||||||||||||||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1) | ||||||||||||||||||||||||||||||||||||||||||||
40-506 | Rev. 1 | |||||||||||||||||||||||||||||||||||||||||||
4090 (Cont.) | FORM CMS-2552-10 | DRAFT | ||||||||||||||||||||||||||||||||||||||||||
HOSPITAL AND HOSPITAL HEALTH CARE | PROVIDER NO.: | PERIOD: | WORKSHEET S-2 | |||||||||||||||||||||||||||||||||||||||||
COMPLEX IDENTIFICATION DATA | FROM_____________ | Part I (CONT.) | ||||||||||||||||||||||||||||||||||||||||||
______________ | TO________________ | |||||||||||||||||||||||||||||||||||||||||||
All Providers | ||||||||||||||||||||||||||||||||||||||||||||
140 | Are there any related organization or home office costs as defined in CMS Pub. 15-1, chapter 10? If yes, and there are home office cost, enter in column 2 the home | 140 | ||||||||||||||||||||||||||||||||||||||||||
office chain number. (See instructions.) If this is facility is part of a chain organization enter the name and address of the home office on lines 111-113. | ||||||||||||||||||||||||||||||||||||||||||||
141 | Name: | Contractor's Name: ___________________ | Contractor's Number: __________ | 141 | ||||||||||||||||||||||||||||||||||||||||
142 | Street: | P. O. Box | 142 | |||||||||||||||||||||||||||||||||||||||||
143 | City: | State: | Zip Code: | 143 | ||||||||||||||||||||||||||||||||||||||||
144 | Are provider based physicians' costs included in Worksheet A? | 144 | ||||||||||||||||||||||||||||||||||||||||||
145 | If you are claiming cost for renal services on Worksheet A, are they inpatient services only? | 145 | ||||||||||||||||||||||||||||||||||||||||||
146 | Have you changed your cost allocation methodology from the previously filed cost report? See | 146 | ||||||||||||||||||||||||||||||||||||||||||
CMS Pub. 15-2, section 4020. If yes, enter the approval date (mm/dd/yyyy) in column 2. | ||||||||||||||||||||||||||||||||||||||||||||
147 | Was there a change in the statistical basis? | 147 | ||||||||||||||||||||||||||||||||||||||||||
148 | Was there a change in the order of allocation? | 148 | ||||||||||||||||||||||||||||||||||||||||||
149 | Was the change to the simplified cost finding method? | 149 | ||||||||||||||||||||||||||||||||||||||||||
If this facility contains a provider that qualifies for an exemption from the application of the lower of costs or charges, enter "Y" for each component and type of service that qualifies for exemption. | ||||||||||||||||||||||||||||||||||||||||||||
Enter "N" if not exempt in the applicable columns below. (See 42 CFR §413.13.) | ||||||||||||||||||||||||||||||||||||||||||||
Part A | Part B | |||||||||||||||||||||||||||||||||||||||||||
1 | 2 | |||||||||||||||||||||||||||||||||||||||||||
155 | Hospital | 155 | ||||||||||||||||||||||||||||||||||||||||||
156 | Subprovider - IPF | 156 | ||||||||||||||||||||||||||||||||||||||||||
157 | Subprovider - IRF | 157 | ||||||||||||||||||||||||||||||||||||||||||
158 | Subprovider - Other | 158 | ||||||||||||||||||||||||||||||||||||||||||
159 | SNF | 159 | ||||||||||||||||||||||||||||||||||||||||||
160 | HHA | 160 | ||||||||||||||||||||||||||||||||||||||||||
161 | CMHC | 161 | ||||||||||||||||||||||||||||||||||||||||||
Multicampus | ||||||||||||||||||||||||||||||||||||||||||||
165 | Is this hospital part of a Multicampus hospital that has one or more campuses in different CBSA? Enter "Y" for yes and "N" for no. | 165 | ||||||||||||||||||||||||||||||||||||||||||
If line 165 is yes, enter the name in col. 0, county in column 1, state in column 2, zip in column 3, CBSA in column 4, | County | State | Zip Code | CBSA | FTE/Campus | |||||||||||||||||||||||||||||||||||||||
FTE/Campus in col. 5. | 1 | 2 | 3 | 4 | 5 | |||||||||||||||||||||||||||||||||||||||
166 | Name: | 166 | ||||||||||||||||||||||||||||||||||||||||||
Health Information Technology incentive in the American Recovery and Reinvestment Act (HIT) | ||||||||||||||||||||||||||||||||||||||||||||
167 | Is this provider a meaningful user under §1886 (n)? Enter "Y" for yes or "N" for no. | 167 | ||||||||||||||||||||||||||||||||||||||||||
168 | If this provider is a CAH, line 105 is "Y" and is a meaningful user, line 167 is "Y" enter the reasonable cost incurred for the HIT assets (see instructions) | 168 | ||||||||||||||||||||||||||||||||||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4004.1) | ||||||||||||||||||||||||||||||||||||||||||||
Rev. 1 | 40-507 | |||||||||||||||||||||||||||||||||||||||||||
4090 (Cont.) | FORM CMS-2552-10 | DRAFT | |||||||
HOSPITAL AND HOSPITAL HEALTH CARE | PROVIDER NO.: | PERIOD: | WORKSHEET S-2 | ||||||
REIMBURSEMENT QUESTIONNAIRE | FROM | Part II | |||||||
TO | |||||||||
General Instruction: For all column 1 responses enter in column 1, "Y" for Yes or "N" for No | |||||||||
For all the dates responses the format will be (mm/dd/yyyy) | |||||||||
Completed by All Hospitals, Provider Organization and Operation | |||||||||
1 | 2 | ||||||||
Y/N | Date | ||||||||
1 | Has the Provider changed ownership immediately prior to the beginning of the cost reporting period? | 1 | |||||||
If column 1 is "Y", enter the date of the change in column 2. (see instructions) | |||||||||
1 | 2 | 3 | |||||||
Y/N | Date | V/I | |||||||
2 | Has the provider terminated participation in the Medicare Program? | 2 | |||||||
If column 1 is yes enter in column 2 the date of termination and in column 3, "V" for voluntary or "I" for involuntary | |||||||||
3 | Is the provider involved in business transactions, including management contracts, with individuals or entities | 3 | |||||||
(e.g., chain home offices, drug or medical supply companies) that are related to the provider or its officers, | |||||||||
medical staff, management personnel, or members of the board of directors through ownership, control, or | |||||||||
family and other similar relationships? (see instructions) | |||||||||
Financial Data and Reports | |||||||||
1 | 2 | 3 | |||||||
Y/N | Type | Date | |||||||
4 | Were the financial statements prepared by a Certified Public Accountant? If column 1 is "Y" enter "A" for Audited, | 4 | |||||||
"C" for Compiled, or "R" for Reviewed in column 2. Submit complete copy or enter date available | |||||||||
in column 3. (see instructions)If column 1 is "N" see instructions. | |||||||||
5 | Are the cost report total expenses and total revenues different from those on the filed financial statements? | 5 | |||||||
If column 1 is "Y", submit reconciliation. | |||||||||
1 | 2 | ||||||||
Approved Educational Activities | Y/N | Legal Oper. | |||||||
6 | Were costs claimed for Nursing School? If column 1 is "Y", enter "Y" or "N" in column 2 to indicate whether the provider is the | 6 | |||||||
legal operator of the program | |||||||||
7 | Were costs claimed for Allied Health Programs? If "Y" see instructions. | 7 | |||||||
8 | Were approvals and/or renewals obtained during the cost reporting period for Nursing School and/or Allied Health Programs? | 8 | |||||||
If "Y", see instructions. | |||||||||
9 | Are Intern-Resident costs claimed on the current cost report? If "Y" see instructions. | 9 | |||||||
10 | Has an Intern-Resident program been initiated or renewed in the current cost reporting period? If "Y" see instructions. | 10 | |||||||
Bad Debts | |||||||||
1 | |||||||||
Y/N | |||||||||
11 | Is the provider seeking reimbursement for bad debts? If "Y", see instructions. | 11 | |||||||
12 | If line 11 is "Y", did the provider's bad debt collection policy change during this cost reporting period? If "Y", submit copy. | 12 | |||||||
13 | If line 11 is "Y", are patient deductibles and/or co-payments waived? If "Y", see instructions. | 13 | |||||||
Bed Complement | |||||||||
14 | Have total beds available changed from prior cost reporting period? If "Y", see instructions. | 14 | |||||||
1 | 2 | 3 | 4 | ||||||
Y/N | Date | Y/N | Date | ||||||
PS&R Data | Part A | Part A | Part B | Part B | |||||
15 | Was the cost report prepared using the PS&R only? If either col. 1 or 3 is "Y", enter the paid through | 15 | |||||||
date of the PS&R used to prepare this cost report in cols. 2 and 4 .(see Instructions.) | |||||||||
16 | Was the cost report prepared using the PS&R for total and the provider's records for allocation? | 16 | |||||||
If either col. 1 or 3 is "Y" enter the paid through date in cols. 2 and 4. (see Instructions) | |||||||||
17 | If line 15 or 16 is "Y", were adjustments made to PS&R data for additional claims that have been | 17 | |||||||
billed but are not included on the PS&R used to file this cost report? If "Y", see Instructions. | |||||||||
18 | If line 15 or 16 is "Y", then were adjustments made to PS&R data for corrections of other | 18 | |||||||
PS&R information? If "Y", see Instructions. | |||||||||
19 | If line 15 or 16 is "Y", then were adjustments made to PS&R data for Other? | 19 | |||||||
Describe the other adjustments: | _________________________________ | ||||||||
20 | Was the cost report prepared only using the provider's records? If "Y" see Instructions. | 20 | |||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4004.2) | |||||||||
40-508 | Rev. 1 | ||||||||
DRAFT | FORM CMS-2552-10 | 4090 (Cont.) | |||||||
HOSPITAL AND HOSPITAL HEALTH CARE | PROVIDER NO.: | PERIOD: | WORKSHEET S-2 | ||||||
REIMBURSEMENT QUESTIONNAIRE | FROM | Part II | |||||||
TO | |||||||||
General Instruction: For all column 1 responses enter in column 1, "Y" for Yes or "N" for No | |||||||||
For all the dates responses the format will be (mm/dd/yyyy) | |||||||||
COMPLETED BY COST REIMBURSED AND TEFRA HOSPITALS ONLY | |||||||||
Capital Related Cost | |||||||||
21 | Have assets been relifed for Medicare purposes? If "Y" see instructions | 21 | |||||||
22 | Have changes occurred in the Medicare depreciation expense due to appraisals made during the cost reporting period? | 22 | |||||||
If "Y", see instructions. | |||||||||
23 | Were new leases and/or amendments to existing leases entered into during this cost reporting period? If "Y", see instructions | 23 | |||||||
24 | Have there been new capitalized leases entered into during the cost reporting period? If "Y" see instructions. | 24 | |||||||
25 | Were assets subject to Sec.2314 of DEFRA acquired during the cost reporting period? If "Y", see instructions. | 25 | |||||||
26 | Has the provider's capitalization policy changed during the cost reporting period? If "Y", submit copy. | 26 | |||||||
Interest Expense | |||||||||
27 | Were new loans, mortgage agreements or letters of credit entered into during the cost reporting period? If "Y", see instructions. | 27 | |||||||
28 | Does the provider have a funded depreciation account and/or bond funds (Debt Service Reserve Fund) treated as a funded depreciation | 28 | |||||||
account? If "Y" see instructions | |||||||||
29 | Has existing debt been replaced prior to its scheduled maturity with new debt? If "Y" see instructions. | 29 | |||||||
30 | Has debt been recalled before scheduled maturity without issuance of new debt? If "Y" see instructions. | 30 | |||||||
Purchased Services | |||||||||
31 | Have changes or new agreements occurred in patient care services furnished through contractual arrangements with suppliers of services? | 31 | |||||||
If "Y" see instructions. | |||||||||
32 | If line 31 is "Y", were the requirements of Sec. 2135.2 applied pertaining to competitive bidding?. | 32 | |||||||
If "N" see instructions. | |||||||||
33 | Are GME costs directly assigned to cost centers other than I/R Services in an Approved Teaching Program on Worksheet A? | 33 | |||||||
If "Y", see instructions. | |||||||||
Provider-Based Physicians | |||||||||
34 | Are services furnished at the provider facility under an arrangement with provider-based physicians? If "Y" see instructions. | 34 | |||||||
35 | If line 34 is "Y", are there new agreements or amended existing agreements with the provider-based physicians during the cost | 35 | |||||||
reporting period? If "Y" (see instructions) | |||||||||
1 | 2 | ||||||||
Home Office Costs | Y/N | Date | |||||||
36 | Are Home Office Cost claimed on the cost report? | 36 | |||||||
37 | If line 36 is "Y", has a home office cost statement been prepared by the home office? If "Y" see instructions. | 37 | |||||||
38 | If line 36 "Y", is the fiscal year end of the home office different from that of the provider? | 38 | |||||||
If column 1 is "Y", enter in column 2 the fiscal year end of the home office. | |||||||||
39 | If line 36 is "Y", does the provider render services to other chain components? If "Y" see instructions. | 39 | |||||||
40 | If line 36 is "Y", does the provider render services to the home office? If "Y" see instructions. | 40 | |||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4004.2) | |||||||||
Rev. 1 | 40-509 |
4090 (Cont.) | FORM CMS-2552-10 | DRAFT | |||||||||||||||
HOSPITAL AND HOSPITAL HEALTH CARE COMPLEX | PROVIDER NO.: | PERIOD | WORKSHEET S-3, | ||||||||||||||
STATISTICAL DATA | FROM ____________ | PART I | |||||||||||||||
____________________ | TO _______________ | ||||||||||||||||
I/P Days / O/P Visits / Trips | Full Time Equivalents | Discharges | |||||||||||||||
Worksheet | |||||||||||||||||
A | Total | Total | Employees | Total | |||||||||||||
Line | No. of | Bed Days | CAH | Title | Title | All | Interns & | On | Nonpaid | Title | Title | All | |||||
Component | Number | Beds | Available | Hours | Title V | XVIII | XIX | Patients | Residents | Payroll | Workers | Title V | XVIII | XIX | Patients | ||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | |||
1 | Hospital Adults & Peds. (columns 5, | 1 | |||||||||||||||
6, 7 and 8 exclude Swing Bed, | |||||||||||||||||
Observation Bed and Hospice days) | |||||||||||||||||
2 | HMO | 2 | |||||||||||||||
3 | HMO IPF | 3 | |||||||||||||||
4 | HMO IRF | 4 | |||||||||||||||
5 | Hospital Adults & Peds. Swing Bed SNF | 5 | |||||||||||||||
6 | Hospital Adults & Peds.Swing Bed NF | 6 | |||||||||||||||
7 | Total Adults and Peds. (exclude | 7 | |||||||||||||||
observation beds) (see instructions) | |||||||||||||||||
8 | Intensive Care Unit | 8 | |||||||||||||||
9 | Coronary Care Unit | 9 | |||||||||||||||
10 | Burn Intensive Care Unit | 10 | |||||||||||||||
11 | Surgical Intensive Care Unit | 11 | |||||||||||||||
12 | Other Special Care | 12 | |||||||||||||||
13 | Nursery | 13 | |||||||||||||||
14 | Total (see instructions) | 14 | |||||||||||||||
15 | CAH visits | 15 | |||||||||||||||
16 | Subprovider - IPF | 16 | |||||||||||||||
17 | Subprovider - IRF | 17 | |||||||||||||||
18 | Subprovider - Other | 18 | |||||||||||||||
19 | Skilled Nursing Facility | 19 | |||||||||||||||
20 | Nursing Facility | 20 | |||||||||||||||
21 | Other Long Term Care | 21 | |||||||||||||||
22 | Home Health Agency | 22 | |||||||||||||||
23 | ASC (Distinct Part) | 23 | |||||||||||||||
24 | Hospice (Distinct Part) | 24 | |||||||||||||||
25 | CMHC | 25 | |||||||||||||||
26 | RHC/FQHC (specify) | 26 | |||||||||||||||
27 | Total (sum of lines 14-26) | 27 | |||||||||||||||
28 | Observation Bed Days | 28 | |||||||||||||||
29 | Ambulance Trips | 29 | |||||||||||||||
30 | Employee discount days (see instruction) | 30 | |||||||||||||||
31 | Employee discount days -IRF | 31 | |||||||||||||||
32 | Labor & delivery days (see instructions) | 32 | |||||||||||||||
33 | LTCH non-covered days | 33 | |||||||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.1) | |||||||||||||||||
40-510 | Rev. 1 | ||||||||||||||||
4090 (Cont.) | FORM CMS-2552-10 | DRAFT | |||||||||||||||
This page is reserved for future use | |||||||||||||||||
Rev. 1 | 40-511 | ||||||||||||||||
4090 (Cont.) | FORM CMS-2552-10 | DRAFT | ||||||
HOSPITAL WAGE INDEX INFORMATION | PROVIDER NO.: | PERIOD: | WORKSHEET S-3, | |||||
FROM __________ | PART II | |||||||
______________ | TO _____________ | |||||||
PART II - WAGE DATA | ||||||||
Worksheet | Reclass. | Adjusted | Paid Hours | Average | ||||
A | of Salaries | Salaries | Related | Hourly Wage | ||||
Line | Amount | (from | (col. 2 ± | to Salaries | (col. 4 ÷ | |||
Number | Reported | Wkst. A-6) | col. 3) | in col. 4 | col. 5) | |||
1 | 2 | 3 | 4 | 5 | 6 | |||
SALARIES | ||||||||
1 | Total salaries (see instructions) | 1 | ||||||
2 | Non-physician anesthetist Part A | 2 | ||||||
3 | Non-physician anesthetist Part B | 3 | ||||||
4 | Physician-Part A | 4 | ||||||
5 | Physician-Part B | 5 | ||||||
6 | Non-physician-Part B | 6 | ||||||
7 | Interns & residents (in an approved program) | 7 | ||||||
8 | Home office personnel | 8 | ||||||
9 | SNF | 9 | ||||||
10 | Excluded area salaries (see instructions) | 10 | ||||||
OTHER WAGES & RELATED COSTS | ||||||||
11 | Contract labor (see instructions) | 11 | ||||||
12 | Management and administrative services | 12 | ||||||
13 | Contract labor: physician-Part A | 13 | ||||||
14 | Home office salaries & wage-related costs | 14 | ||||||
15 | Home office: physician Part A | 15 | ||||||
16 | Teaching physician salaries (see instructions) | 16 | ||||||
WAGE-RELATED COSTS | ||||||||
17 | Wage-related costs (core) Wkst S-3, Part IV line 24 | 17 | ||||||
18 | Wage-related costs (other)Wkst S-3, Part IV line 25 | 18 | ||||||
19 | Excluded areas | 19 | ||||||
20 | Non-physician anesthetist Part A | 20 | ||||||
21 | Non-physician anesthetist Part B | 21 | ||||||
22 | Physician Part A | 22 | ||||||
23 | Physician Part B | 23 | ||||||
24 | Wage-related costs (RHC/FQHC) | 24 | ||||||
25 | Interns & residents (in an approved program) | 25 | ||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.2 - 4005.3) | ||||||||
46-512 | Rev. 1 | |||||||
DRAFT | FORM CMS-2552-10 | 4090 (Cont.) | ||||||
HOSPITAL WAGE INDEX INFORMATION | PROVIDER NO.: | PERIOD: | WORKSHEET S-3, | |||||
FROM __________ | PART II & III | |||||||
______________ | TO _____________ | |||||||
PART II - WAGE DATA | ||||||||
Worksheet | Reclass. | Adjusted | Paid Hours | Average | ||||
A | of Salaries | Salaries | Related | Hourly Wage | ||||
Line | Amount | (from | (col. 2 ± | to Salaries | (col. 4 ÷ | |||
Number | Reported | Wkst. A-6) | col. 3) | in col. 4 | col. 5) | |||
1 | 2 | 3 | 4 | 5 | 6 | |||
OVERHEAD COSTS - DIRECT SALARIES | ||||||||
26 | Employee Benefits | 26 | ||||||
27 | Administrative & General | 27 | ||||||
28 | Administrative & General under contract (see inst.) | 28 | ||||||
29 | Maintenance & Repairs | 29 | ||||||
30 | Operation of Plant | 30 | ||||||
31 | Laundry & Linen Service | 31 | ||||||
32 | Housekeeping | 32 | ||||||
33 | Housekeeping under contract (see instructions) | 33 | ||||||
34 | Dietary | 34 | ||||||
35 | Dietary under contract (see instructions) | 35 | ||||||
36 | Cafeteria | 36 | ||||||
37 | Maintenance of Personnel | 37 | ||||||
38 | Nursing Administration | 38 | ||||||
39 | Central Services and Supply | 39 | ||||||
40 | Pharmacy | 40 | ||||||
41 | Medical Records & Medical Records Library | 41 | ||||||
42 | Social Service | 42 | ||||||
43 | Other General Service | 43 | ||||||
PART III - HOSPITAL WAGE INDEX SUMMARY | ||||||||
1 | Net salaries (see instructions) | 1 | ||||||
2 | Excluded area salaries (see instructions) | 2 | ||||||
3 | Subtotal salaries (line 1 minus line 2) | 3 | ||||||
4 | Subtotal other wages & related costs (see inst.) | 4 | ||||||
5 | Subtotal wage-related costs (see inst.) | 5 | ||||||
6 | Total (sum of lines 3 thru 5) | 6 | ||||||
7 | Total overhead cost (see instructions | 7 | ||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.2 - 4005.3) | ||||||||
Rev. 1 | 40-513 |
4090 (Cont.) | FORM CMS-2552-10 | DRAFT | |||||||
HOSPITAL WAGE RELATED COSTS | PROVIDER NO.: | PERIOD: | WORKSHEET S-3, | ||||||
FROM __________ | PART IV | ||||||||
______________ | TO _____________ | ||||||||
PART IV - Wage Related Cost | |||||||||
Part A - Core List | |||||||||
Amount | |||||||||
Reported | |||||||||
RETIREMENT COST | |||||||||
1 | 401K Employer Contributions | 1 | |||||||
2 | Tax Sheltered Annuity (TSA) Employer Contribution | 2 | |||||||
3 | Qualified and Non-Qualified Pension Plan Cost | 3 | |||||||
4 | Prior Year Pension Service Cost | 4 | |||||||
PLAN ADMINISTRATIVE COSTS (Paid to External Organization): | |||||||||
5 | 401K/TSA Plan Administration fees | 5 | |||||||
6 | Legal/Accounting/Management Fees-Pension Plan | 6 | |||||||
7 | Employee Managed Care Program Administration Fees | 7 | |||||||
HEALTH AND INSURANCE COST | |||||||||
8 | Health Insurance (Purchased or Self Funded) | 8 | |||||||
9 | Prescription Drug Plan | 9 | |||||||
10 | Dental, Hearing and Vision Plan | 10 | |||||||
11 | Life Insurance (If employee is owner or beneficiary) | 11 | |||||||
12 | Accidental Insurance (If employee is owner or beneficiary) | 12 | |||||||
13 | Disability Insurance (If employee is owner or beneficiary) | 13 | |||||||
14 | Long-Term Care Insurance (If employee is owner or beneficiary) | 14 | |||||||
15 | Workers' Compensation Insurance | 15 | |||||||
16 | Retirement Health Care Cost (Only current year, not the extraordinary accrual required by FASB 106. Non cumulative portion) | 16 | |||||||
TAXES | |||||||||
17 | FICA-Employers Portion Only | 17 | |||||||
18 | Medicare Taxes - Employers Portion Only | 18 | |||||||
19 | Unemployment Insurance | 19 | |||||||
20 | State or Federal Unemployment Taxes | 20 | |||||||
OTHER | |||||||||
21 | Executive Deferred Compensation | 21 | |||||||
22 | Day Care Cost and Allowances | 22 | |||||||
23 | Tuition Reimbursement | 23 | |||||||
24 | Total Wage Related cost (Sum of lines 1 -23) | 24 | |||||||
Part B Other than Core Related Cost | |||||||||
25 | Other Wage Related Costs (specify)_________________________________________ | 25 | |||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.4) | |||||||||
40-514 | Rev. 1 |
DRAFT | FORM CMS-2552-10 | 4090 (Cont.) | ||||
HOSPITAL CONTRACT LABOR AND BENEFIT COST | PROVIDER NO.: | PERIOD: | WORKSHEET S-3, | |||
FROM __________ | PART V | |||||
______________ | TO _____________ | |||||
PART V - Contract Labor and Benefit Cost | ||||||
Hospital and Hospital-Based Component Identification: | ||||||
Provider | Contract | Benefit | ||||
Component | Component Name | Number | Labor | Cost | ||
0 | 1 | 2 | 3 | 4 | ||
1 | Total facility's contract labor and benefit cost | 1 | ||||
2 | Hospital | 2 | ||||
3 | Subprovider- IPF | 3 | ||||
4 | Subprovider- IRF | 4 | ||||
5 | Subprovider- (Other) | 5 | ||||
6 | Swing Beds-SNF | 6 | ||||
7 | Swing Beds-NF | 7 | ||||
8 | Hospital-Based SNF | 8 | ||||
9 | Hospital-Based NF | 9 | ||||
10 | Hospital-Based OLTC | 10 | ||||
11 | Hospital-Based HHA | 11 | ||||
12 | Separately Certified ASC | 12 | ||||
13 | Hospital-Based Hospice | 13 | ||||
14 | Hospital-Based Health Clinic RHC | 14 | ||||
15 | Hospital-Based Health Clinic FQHC | 15 | ||||
16 | Hospital-Based-CMHC | 16 | ||||
17 | Renal Dialysis | 17 | ||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4005.5) | ||||||
Rev. 1 | 40-515 |
4090 (Cont.) | FORM CMS-2552-10 | DRAFT | ||||||||||||||||||||||||
HOSPITAL-BASED HOME HEALTH AGENCY | PROVIDER NO.: | PERIOD: | WORKSHEET S-4 | {APP4}IALLWAYS~/PCOPB1~Q/PGQ/1 | ||||||||||||||||||||||
STATISTICAL DATA | _______________ | FROM ____________ | ||||||||||||||||||||||||
HHA NO.: | TO _______________ | |||||||||||||||||||||||||
_______________ | ||||||||||||||||||||||||||
HOME HEALTH AGENCY STATISTICAL DATA | County: __________________ | |||||||||||||||||||||||||
Title | Title | Title | ||||||||||||||||||||||||
DESCRIPTION | V | XVIII | XIX | Other | Total | |||||||||||||||||||||
1 | 2 | 3 | 4 | 5 | ||||||||||||||||||||||
1 | Home Health Aide Hours | 1 | ||||||||||||||||||||||||
2 | Unduplicated Census Count (see instructions) | 2 | ||||||||||||||||||||||||
HOME HEALTH AGENCY - NUMBER OF EMPLOYEES | ||||||||||||||||||||||||||
(FULL TIME EQUIVALENT) | ||||||||||||||||||||||||||
Enter the number of hours in | ||||||||||||||||||||||||||
your normal work week _______ | Staff | Contract | Total | |||||||||||||||||||||||
1 | 2 | 3 | ||||||||||||||||||||||||
3 | Administrator and Assistant Administrator(s) | 3 | ||||||||||||||||||||||||
4 | Directors and Assistant Director(s) | 4 | ||||||||||||||||||||||||
5 | Other Administrative Personnel | 5 | ||||||||||||||||||||||||
6 | Direct Nursing Service | 6 | ||||||||||||||||||||||||
7 | Nursing Supervisor | 7 | ||||||||||||||||||||||||
8 | Physical Therapy Service | 8 | ||||||||||||||||||||||||
9 | Physical Therapy Supervisor | 9 | ||||||||||||||||||||||||
10 | Occupational Therapy Service | 10 | ||||||||||||||||||||||||
11 | Occupational Therapy Supervisor | 11 | ||||||||||||||||||||||||
12 | Speech Pathology Service | 12 | ||||||||||||||||||||||||
13 | Speech Pathology Supervisor | 13 | ||||||||||||||||||||||||
14 | Medical Social Service | 14 | ||||||||||||||||||||||||
15 | Medical Social Service Supervisor | 15 | ||||||||||||||||||||||||
16 | Home Health Aide | 16 | ||||||||||||||||||||||||
17 | Home Health Aide Supervisor | 17 | ||||||||||||||||||||||||
18 | Other (specify) | 18 | ||||||||||||||||||||||||
HOME HEALTH AGENCY CBSA CODES | ||||||||||||||||||||||||||
1 | ||||||||||||||||||||||||||
19 | How many CBSAs in column 1 did you provide services to during this cost reporting period. | 19 | ||||||||||||||||||||||||
20 | List those CBSA code(s) in column 1 serviced during this cost reporting period (line 20 contains the first code). | 20 | ||||||||||||||||||||||||
PPS ACTIVITY DATA | ||||||||||||||||||||||||||
Full Episodes | ||||||||||||||||||||||||||
Without | With | LUPA | PEP only | Total | ||||||||||||||||||||||
Outliers | Outliers | Episodes | Episodes | (cols. 1-4) | ||||||||||||||||||||||
1 | 2 | 3 | 4 | 5 | ||||||||||||||||||||||
21 | Skilled Nursing Visits | 21 | ||||||||||||||||||||||||
22 | Skilled Nursing Visit Charges | 22 | ||||||||||||||||||||||||
23 | Physical Therapy Visits | 23 | ||||||||||||||||||||||||
24 | Physical Therapy Visit Charges | 24 | ||||||||||||||||||||||||
25 | Occupational Therapy Visits | 25 | ||||||||||||||||||||||||
26 | Occupational Therapy Visit Charges | 26 | ||||||||||||||||||||||||
27 | Speech Pathology Visits | 27 | ||||||||||||||||||||||||
28 | Speech Pathology Visit Charges | 28 | ||||||||||||||||||||||||
29 | Medical Social Service Visits | 29 | ||||||||||||||||||||||||
30 | Medical Social Service Visit Charges | 30 | ||||||||||||||||||||||||
31 | Home Health Aide Visits | 31 | ||||||||||||||||||||||||
32 | Home Health Aide Visit Charges | 32 | ||||||||||||||||||||||||
33 | Total visits (sum of lines 21, 23, 25, 27, 29, and 31) | 33 | ||||||||||||||||||||||||
34 | Other Charges | 34 | ||||||||||||||||||||||||
35 | Total Charges (sum of lines 22, 24, 26, 28, 30, 32, and 34) | 35 | ||||||||||||||||||||||||
36 | Total Number of Episodes (standard/non outlier) | 36 | ||||||||||||||||||||||||
37 | Total Number of Outlier Episodes | 37 | ||||||||||||||||||||||||
38 | Total Non-Routine Medical Supply Charges | 38 | ||||||||||||||||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4006) | ||||||||||||||||||||||||||
40-516 | Rev. 1 |
DRAFT | FORM CMS-2552-10 | 4090 (Cont.) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
HOSPITAL RENAL DIALYSIS DEPARTMENT | PROVIDER NO.: | PERIOD: | WORKSHEET S-5 | {APP4}IALLWAYS~/PCOPB1~Q/PGQ/1 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
STATISTICAL DATA | ________________ | FROM ___________ | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
TO ______________ | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
RENAL DIALYSIS STATISTICS | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Outpatient | Training | Home | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Hemo- | CAPD | Hemo- | CAPD | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
DESCRIPTION | Regular | High Flux | dialysis | CCPD | dialysis | CCPD | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1 | 2 | 3 | 4 | 5 | 6 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1 | Number of patients in program at | 1 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
end of cost reporting period | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2 | Number of times per week patient | 2 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
receives dialysis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3 | Average patient dialysis time including setup | 3 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4 | CAPD exchanges per day | 4 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5 | Number of days in year dialysis furnished | 5 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6 | Number of stations | 6 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7 | Treatment capacity per day per station | 7 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8 | Utilization (see instructions) | 8 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9 | Average times dialyzers re-used | 9 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10 | Percentage of patients re-using dialyzers | 10 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
TRANSPLANT INFORMATION | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11 | Number of patients on transplant list | 11 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12 | Number of patients transplanted during the cost reporting period | 12 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
EPOETIN | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13 | Net costs of Epoetin furnished to all maintenance dialysis patients by the provider. | 13 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14 | Epoetin amount from Worksheet A for Home Dialysis program | 14 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15 | Number of EPO units furnished relating to the renal dialysis department | 15 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16 | Number of EPO units furnished relating to the home dialysis department | 16 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
ARANESP | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17 | Net costs of ARANESP furnished to all maintenance dialysis patients by the provider. | 17 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18 | ARANESP amount from Worksheet A for Home Dialysis program | 18 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19 | Number of ARANESP units furnished relating to the renal dialysis department | 19 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20 | Number of ARANESP units furnished relating to the home dialysis department | 20 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
PHYSICIAN PAYMENT METHOD (enter "X" if method(s) is applicable) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21 | MCP_________ | INITIAL METHOD__________ | 21 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4007) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Rev. 1 | 40-517 |
4090 (Cont.) | FORM CMS-2552-10 | DRAFT | ||||||||||||||||||||||||||||
HOSPITAL-BASED COMMUNITY MENTAL HEALTH CENTER AND | PROVIDER NO.: | PERIOD: | WORKSHEET S-6 | . | ||||||||||||||||||||||||||
OTHER OUTPATIENT REHABILITATION | _______________ | FROM__________ | ||||||||||||||||||||||||||||
PROVIDER STATISTICAL DATA | COMPONENT NO.: | TO_____________ | ||||||||||||||||||||||||||||
_______________ | ||||||||||||||||||||||||||||||
COMMUNITY MENTAL HEALTH & OTHER OUTPATIENT REHABILITATION PROVIDER- NUMBER OF EMPLOYEES (FULL TIME EQUIVALENT) | ||||||||||||||||||||||||||||||
Check | [ ] CMHC [ ] OOT | |||||||||||||||||||||||||||||
Applicable | [ ] CORF [ ] OSP | |||||||||||||||||||||||||||||
Box | [ ] OPT | |||||||||||||||||||||||||||||
Enter the number of hours in your normal workweek ________ | ||||||||||||||||||||||||||||||
Total | ||||||||||||||||||||||||||||||
Staff | Contract | (col. 1 + col. 2) | ||||||||||||||||||||||||||||
1 | 2 | 3 | ||||||||||||||||||||||||||||
1 | Administrator and Assistant Administrator(s) | 1 | ||||||||||||||||||||||||||||
2 | Director(s) and Assistant Director(s) | 2 | ||||||||||||||||||||||||||||
3 | Other Administrative Personnel | 3 | ||||||||||||||||||||||||||||
4 | Direct Nursing Service | 4 | ||||||||||||||||||||||||||||
5 | Nursing Supervisor | 5 | ||||||||||||||||||||||||||||
6 | Physical Therapy Service | 6 | ||||||||||||||||||||||||||||
7 | Physical Therapy Supervisor | 7 | ||||||||||||||||||||||||||||
8 | Occupational Therapy Service | 8 | ||||||||||||||||||||||||||||
9 | Occupational Therapy Supervisor | 9 | ||||||||||||||||||||||||||||
10 | Speech Pathology Service | 10 | ||||||||||||||||||||||||||||
11 | Speech Pathology Supervisor | 11 | ||||||||||||||||||||||||||||
12 | Medical Social Service | 12 | ||||||||||||||||||||||||||||
13 | Medical Social Service Supervisor | 13 | ||||||||||||||||||||||||||||
14 | Respiratory Therapy Service | 14 | ||||||||||||||||||||||||||||
15 | Respiratory Therapy Supervisor | 15 | ||||||||||||||||||||||||||||
16 | Psychiatric/Psychological Service | 16 | ||||||||||||||||||||||||||||
17 | Psychiatric/Psychological Service Supervisor | 17 | ||||||||||||||||||||||||||||
18 | Other (specify) | 18 | ||||||||||||||||||||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4008) | ||||||||||||||||||||||||||||||
40-518 | Rev. 1 |
DRAFT | FORM CMS-2552-10 | 4090 (Cont.) | ||||||||||
PROSPECTIVE PAYMENT FOR SNF | PROVIDER NO.: | PERIOD: | WORKSHEET S-7 | |||||||||
STATISTICAL DATA | FROM ____________ | |||||||||||
________________ | TO _______________ | |||||||||||
If this facility contains a hospital-based SNF, are all patients are under managed care or there was no | ||||||||||||
1 | Medicare utilization enter "Y" and do not complete the rest of this worksheet. | 1 | ||||||||||
Does this hospital have an agreement under either section 1883 or section 1913 for swing | ||||||||||||
2 | beds? If yes, enter the agreement date (mm/dd/yyyy) in column 2. | 2 | ||||||||||
SNF | Swing Bed SNF | TOTAL | ||||||||||
GROUP | Days | Days | (sum of col. 2 + 3) | |||||||||
1 | 2 | 3 | 4 | |||||||||
3 | RUC | 3 | ||||||||||
4 | RUB | 4 | ||||||||||
5 | RUA | 5 | ||||||||||
6 | RUX | 6 | ||||||||||
7 | RUL | 7 | ||||||||||
8 | RVC | 8 | ||||||||||
9 | RVB | 9 | ||||||||||
10 | RVA | 10 | ||||||||||
11 | RVX | 11 | ||||||||||
12 | RVL | 12 | ||||||||||
13 | RHC | 13 | ||||||||||
14 | RHB | 14 | ||||||||||
15 | RHA | 15 | ||||||||||
16 | RHX | 16 | ||||||||||
17 | RHL | 17 | ||||||||||
18 | RMC | 18 | ||||||||||
19 | RMB | 19 | ||||||||||
20 | RMA | 20 | ||||||||||
21 | RMX | 21 | ||||||||||
22 | RML | 22 | ||||||||||
23 | RLB | 23 | ||||||||||
24 | RLA | 24 | ||||||||||
25 | RLX | 25 | ||||||||||
26 | SE3 | 26 | ||||||||||
27 | SE2 | 27 | ||||||||||
28 | SE1 | 28 | ||||||||||
29 | SSC | 29 | ||||||||||
30 | SSB | 30 | ||||||||||
31 | SSA | 31 | ||||||||||
32 | CC2 | 32 | ||||||||||
33 | CC1 | 33 | ||||||||||
34 | CB2 | 34 | ||||||||||
35 | CB1 | 35 | ||||||||||
36 | CA2 | 36 | ||||||||||
37 | CA1 | 37 | ||||||||||
38 | IB2 | 38 | ||||||||||
39 | IB1 | 39 | ||||||||||
40 | IA2 | 40 | ||||||||||
41 | IA1 | 41 | ||||||||||
42 | BB2 | 42 | ||||||||||
43 | BB1 | 43 | ||||||||||
44 | BA2 | 44 | ||||||||||
45 | BA1 | 45 | ||||||||||
46 | PE2 | 46 | ||||||||||
47 | PE1 | 47 | ||||||||||
48 | PD2 | 48 | ||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4009) | ||||||||||||
Rev. 1 | 40-519 | |||||||||||
4090 (Cont.) | FORM CMS-2552-10 | DRAFT | ||||||||||
PROSPECTIVE PAYMENT FOR SNF | PROVIDER NO.: | PERIOD: | WORKSHEET S-7 | |||||||||
STATISTICAL DATA | FROM ____________ | |||||||||||
________________ | TO _______________ | |||||||||||
SNF | Swing Bed SNF | TOTAL | ||||||||||
GROUP | Days | Days | (sum of col. 2 + 3) | |||||||||
1 | 2 | 3 | 4 | |||||||||
49 | PD1 | 49 | ||||||||||
50 | PC2 | 50 | ||||||||||
51 | PC1 | 51 | ||||||||||
52 | PB2 | 52 | ||||||||||
53 | PB1 | 53 | ||||||||||
54 | PA2 | 54 | ||||||||||
55 | PA1 | 55 | ||||||||||
56 | Default rate | 56 | ||||||||||
57 | TOTAL | 57 | ||||||||||
SNF SERVICES | ||||||||||||
Enter in column 1 the SNF CBSA code or 5 character code if Rural based facility, in effect at the beginning of the cost | ||||||||||||
58 | reporting period. Enter in column 2, the code in effect on or after October 1, of the cost reporting period (if applicable). | 58 | ||||||||||
A notice published in the "Federal Register" Vol. 68, No. 149 August 4, 2003 provided for an increase in the RUG payments beginning 10/01/2003. Congress | ||||||||||||
expected this increase to be used for direct patient care and related expenses. Enter in column 1 the amount of the expense for each category. Enter in | ||||||||||||
column 2 the percentage of total expenses for each category to total SNF revenue from Worksheet G-2, Part I, line 6, column 3. Indicate in column 3 "Y" | ||||||||||||
for yes or "N" for no if the spending reflects increases associated with direct patient care and related expenses for each category. (See instructions) | ||||||||||||
Expenses | Percentage | Y/N | ||||||||||
59 | Staffing | 59 | ||||||||||
60 | Recruitment | 60 | ||||||||||
61 | Retention of employees | 61 | ||||||||||
62 | Training | 62 | ||||||||||
63 | Other (Specify) | 63 | ||||||||||
64 | Total SNF revenue (Worksheet G-2, Part I, line 6, column 3) | 64 | ||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4009) | ||||||||||||
40-520 | Rev. 1 |
DRAFT | FORM CMS-2552-10 | 4090 (Cont.) | ||||||||||||||||
PROVIDER-BASED RURAL HEALTH CLINIC/ | PROVIDER NO.: | PERIOD: | WORKSHEET S-8 | |||||||||||||||
FEDERALLY QUALIFIED HEALTH CENTER | _____________ | FROM________ | ||||||||||||||||
PROVIDER STATISTICAL DATA | COMPONENT NO.: | TO___________ | ||||||||||||||||
_____________ | ||||||||||||||||||
Check | [ ] RHC | |||||||||||||||||
Applicable Box: | [ ] FQHC | |||||||||||||||||
Clinic Address and Identification: | ||||||||||||||||||
1 | Street: | 1 | ||||||||||||||||
2 | City: | State: | Zip Code: | County: | 2 | |||||||||||||
3 | Designation (for FQHCs only) - Enter "R" for rural or "U" for urban | 3 | ||||||||||||||||
Source of Federal Funds: | Grant Award | Date | ||||||||||||||||
1 | 2 | |||||||||||||||||
4 | Community Health Center (Section 330(d), PHS Act) | 4 | ||||||||||||||||
5 | Migrant Health Center (Section 329(d), PHS Act) | 5 | ||||||||||||||||
6 | Health Services for the Homeless (Section 340(d), PHS Act) | 6 | ||||||||||||||||
7 | Appalachian Regional Commission | 7 | ||||||||||||||||
8 | Look-Alikes | 8 | ||||||||||||||||
9 | Other (specify) | 9 | ||||||||||||||||
10 | Does this facility operate as other than an RHC or FQHC? Enter "Y" for yes and "N" for no in column 1. If yes, indicate number of | 10 | ||||||||||||||||
other operations in column 2.(Enter in subscripts of line 12 the type of other operation(s) and the operating hours.) | ||||||||||||||||||
Facility hours of operations (1) | ||||||||||||||||||
Sunday | Monday | Tuesday | Wednesday | Thursday | Friday | Saturday | ||||||||||||
Type Operation | from | to | from | to | from | to | from | to | from | to | from | to | from | to | ||||
0 | 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | ||||
11 | Clinic | 11 | ||||||||||||||||
(1) Enter clinic hours of operation on line 13 and other type operations on subscripts of line 13 (both type and hours of operation). | ||||||||||||||||||
List hours of operation based on a 24 hour clock. For example: 8:00am is 0800, 6:30pm is 1830, and midnight is 2400. | ||||||||||||||||||
12 | Have you received an approval for an exception to the productivity standard? | 12 | ||||||||||||||||
13 | Is this a consolidated cost report as defined in CMS Pub. 27, section 508(D)? If yes, enter in column 2 the | 13 | ||||||||||||||||
number of providers included in this report. List the names of all providers and numbers below. | ||||||||||||||||||
14 | Provider name: _______________________________________________ | CCN number: ________________ | 14 | |||||||||||||||
1 | 2 | 3 | 4 | |||||||||||||||
Y/N | V | XVIII | XIX | |||||||||||||||
Have you provided all or substantially all GME costs. Enter in column 1 ,"Y" for yes and "N" for no col. 1. | ||||||||||||||||||
15 | If yes, enter in col. 2, 3 and 4 the number of program visits performed by Intern & Residents. (See instructions) | 15 | ||||||||||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4010) | ||||||||||||||||||
Rev. 1 | 40-521 |
4090 (Cont.) | FORM CMS-2552-10 | DRAFT | ||||||
HOSPICE IDENTIFICATION DATA | PROVIDER NO.:__________ | PERIOD: | WORKSHEET S-9, | |||||
FROM _____________ | PARTS I & II | |||||||
HOSPICE NO.:___________ | TO ________________ | |||||||
PART I - ENROLLMENT DAYS | ||||||||
Unduplicated Days | ||||||||
Title XVIII | ||||||||
Skilled | Title XIX | Total | ||||||
Nursing | Nursing | All | (sum of | |||||
Enrollment Days | Title XVIII | Title XIX | Facility | Facility | Other | cols. 1, 2 & 5) | ||
1 | 2 | 3 | 4 | 5 | 6 | |||
1 | Continuous Home Care | 1 | ||||||
2 | Routine Home Care | 2 | ||||||
3 | Inpatient Respite Care | 3 | ||||||
4 | General Inpatient Care | 4 | ||||||
5 | Total Hospice Days | 5 | ||||||
PART II - CENSUS DATA | ||||||||
Title XVIII | ||||||||
Skilled | Title XIX | Total | ||||||
Nursing | Nursing | All | (sum of | |||||
Title XVIII | Title XIX | Facility | Facility | Other | cols. 1, 2 & 5) | |||
1 | 2 | 3 | 4 | 5 | 6 | |||
6 | Number of Patients Receiving Hospice Care | 6 | ||||||
7 | Total Number of Unduplicated Continuous | 7 | ||||||
Care Hours Billable to Medicare | ||||||||
8 | Average Length of Stay (line 5/line 6) | 8 | ||||||
9 | Unduplicated Census Count | 9 | ||||||
NOTE: Parts I & II, columns 1 and 2 also include the days reported in columns 3 and 4 . | ||||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II, SECTIONS 4011) | ||||||||
40-522 | Rev. 1 |
DRAFT | FORM CMS-2552-10 | 4090 (Cont.) | ||||||
HOSPITAL UNCOMPENSATED AND INDIGENT | PROVIDER NO.: | PERIOD: | WORKSHEET S-10 | |||||
CARE DATA | FROM_____________ | |||||||
______________ | TO________________ | |||||||
Uncompensated and indigent care cost computation | 1 | |||||||
1 | Cost to charge ratio (Worksheet C, Part I line 200 column 3 divided by line 200 column 8) | 1 | ||||||
Medicaid (see instructions for each line) | ||||||||
2 | Net revenue from Medicaid | 2 | ||||||
3 | Did you receive DSH or supplemental payments from Medicaid? | 3 | ||||||
4 | If line 3 is "yes", does line 2 include all DSH or supplemental payments from Medicaid? | 4 | ||||||
5 | If line 4 is "no", then enter DSH or supplemental payments from Medicaid | 5 | ||||||
6 | Medicaid charges | 6 | ||||||
7 | Medicaid cost (line 1 times line 6) | 7 | ||||||
8 | Difference between net revenue and costs for Medicaid program (line 2 plus line 5 minus line 7) | 8 | ||||||
State Children's Health Insurance Program (SCHIP) (see instructions for each line) | ||||||||
9 | Net revenue from stand-alone SCHIP | 9 | ||||||
10 | Stand-alone SCHIP charges | 10 | ||||||
11 | Stand-alone SCHIP cost (line 1 times line 10) | 11 | ||||||
12 | Difference between net revenue and costs for stand-alone SCHIP (line 9 minus line 11) | 12 | ||||||
Other state or local government indigent care program (see instructions for each line) | ||||||||
13 | Net revenue from state or local indigent care program (Not included on lines 2, 5 or 9) | 13 | ||||||
14 | Charges for patients covered under state or local indigent care program (Not included in lines 6 or 10) | 14 | ||||||
15 | State or local indigent care program cost (line 1 times line 14) | 15 | ||||||
16 | Difference between net revenue and costs for state or local indigent care program (line 13 minus line 15) | 16 | ||||||
Uncompensated care (see instructions for each line) | ||||||||
17 | Private grants, donations, or endowment income restricted to funding charity care | 17 | ||||||
18 | Government grants, appropriations or transfers for support of hospital operations | 18 | ||||||
19 | Total unreimbursed cost for Medicaid , SCHIP and state and local indigent care programs (sum of lines 8, 12 and 16) | 19 | ||||||
Uninsured | Insured | Total | ||||||
patients | patients | (col. 1 + col. 2) | ||||||
1 | 2 | 3 | ||||||
20 | Total initial obligation of patients approved for charity care (at full charges excluding | 20 | ||||||
non-reimbursable cost centers) for the entire facility | ||||||||
21 | Cost of initial obligation of patients approved for charity care (line 1 times line 20) | 21 | ||||||
22 | Partial payment by patients approved for charity care | 22 | ||||||
23 | Cost of charity care (line 21 minus line 22) | 23 | ||||||
1 | ||||||||
Does the amount in line 20 column 2 include charges for patient days beyond a length of stay limit imposed on | ||||||||
24 | patients covered by Medicaid or other indigent care program? | 24 | ||||||
25 | If line 24 is "yes," charges for patient days beyond an indigent care program's length of stay limit | 25 | ||||||
26 | Total bad debt expense for the entire facility (see instructions) | 26 | ||||||
27 | Medicare bad debts for §1886(d) hospitals fromWorksheets E, Part A and E, Part B, or CAHs from Worksheet E-3, Part V. | 27 | ||||||
28 | Non-Medicare and Non-Reimbursable bad debt expense (line 26 minus line 27) | 28 | ||||||
29 | Cost of non-Medicare bad debt expense (line 1 times line 28) | 29 | ||||||
30 | Cost of non-Medicare uncompensated care (line 23 column 3 plus line 29) | 30 | ||||||
31 | Total unreimbursed and uncompensated care cost (line 19 plus line 30) | 31 | ||||||
FORM CMS-2552-10 (DRAFT) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 4012) | ||||||||
Rev. 1 | 40-523 |
File Type | application/vnd.ms-excel |
File Title | WORKSHEETS |
Author | Nadia Massuda |
Last Modified By | CMS |
File Modified | 2010-06-17 |
File Created | 2004-09-09 |