CMS-265-94 Medicare Cost Report Forms

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Overview

Sheet1
Notes
ws-S
ws-s1
ws-A
ws-A-1
ws-A-2
ws-A-3
ws-A-4^
ws-B^
ws-B-1^
ws-C^
ws-D^

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Sheet 1: Sheet1

Medicare

Cost Report

Forms

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Sheet 2: Notes

^ Indicates revised worksheets in current transmittal.

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Sheet 3: ws-S

03-05			Form CMS 265-94				3490 (Cont.)
This report is required by law (42 USC. 1395g: CFR 413.20(b)). Failure to report can result						FORM APPROVED
in all payments made during the reporting period being deemed overpayments (42 USC 1395g).						OMB NO: 0938-0236
INDEPENDENT RENAL DIALYSIS FACILITY				PROVIDER NO:	PERIOD:	WORKSHEET
COST REPORT CERTIFICATION					From:_________	S
				_______________	To: ____________
Intermediary Use Only:
		[ ] Audited	Date Received ________________		[ ] Initial	[ ] Re-opened
		[ ] Desk Reviewed	Intermediary No. ______________		[ ] Final
PART I - GENERAL
Check			[ ] Electronic filed cost report		Date:
applicable box			[ ] Manually submitted cost report		Time:
1	Name:						1
1.01	Street:				P.O. Box:		1.01
1.02	City:		State:		Zip Code:		1.02
1.03	County:						1.03
2	Provider Number:						2
3	Date Certified:						3
4	Name :			Phone Number:			4
5	Cost reporting period (mm/dd/yyyy)			From:_________	To: ____________		5
					1	2
6	Type of control (see instructions)						6
					1	2
7	Type of Physicians' Reimbursement (see instructions)						7
8	Was this facility previously certified as a hospital-based unit?						8
	Enter "Y" for yes or "N" for no.
9	If you are part of a chain organization enter "y" for yes and enter the name and address of the home office,						9
	if not, enter "N" for no.
9.01	Name:						9.01
9.02	Street:				P.O. Box:		9.02
9.03	City:		State:		Zip Code:		9.03
PART II - CERTIFICATION BY OFFICER OR ADMINISTRATOR
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.
I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying cost report prepared by ________________________
______________________(Provider Name and Number) for the cost report period beginning ________________ and ending__________________and that
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 and that the services identified in this cost report were provided in compliance with such laws and regulation.
(Signed)
Officer or Administrator of Facility				Title		Date
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 0938-0236. The time required to complete this information collection is estimated to average 50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.
FORM CMS-265-94 (3-2005) ( INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,
SECTIONS 3404, 3404.1 AND 3404.2)
Rev. 7							34-303

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Sheet 4: ws-s1

3490 (Cont.)			Form CMS-265-94				03-05
		INDEPENDENT	PROVIDER NO.:	PERIOD:
		RENAL DIALYSIS FACILITY		FROM_______________		WORKSHEET S-1
		STATISTICAL DATA	___________________	TO________________
		RENAL DIALYSIS STATISTICS
			OUTPATIENT		TRAINING
				PERITONEAL		PERITONEAL
			HEMODIALYSIS	DIALYSIS	HEMODIALYSIS	DIALYSIS
			1	2	3	4
1	Number of treatments not billed to Medicare and						1
	furnished directly
2	Number of treatments not billed to Medicare and						2
	furnished under arrangements
3	Number of patients currently in dialysis program						3
4	Average times per week patient receives dialysis						4
5	Number of days in an average week for patient						5
	dialysis treatments
6	Average time of patient dialysis treatment						6
	including set up time
7	Number of machines regularly available for use						7
8	Number of standby machines						8
9	Number of shifts in typical week during regular						9
	reporting period
10	Hours per shift in typical week during regular						10
	reporting period
	.01	First shift					.01
	.02	Second Shift					.02
	.03	Third shift					.03
11	Number of treatments provided						11
	.01	One (1) time per week					.01
	.02	Two (2) times per week					.02
	.03	Three (3) times per week					.03
	.04	More than three (3) times per week					.04
	.05	Total					.05
				Type of Dialyzers	Dialyzer Reuse Count	Other Dialyzers
				1	2	3
12	Type of dialyzers used. If dialyzers are reused, indicate the number of times (see instruction)						12
13	Number of back-up sessions furnished to home patients (see instructions)						13
14	Number of units of epoetin furnished during cost reporting period						14
			TRANSPLANT STATISTICS
15	Number of patients who are awaiting transplants						15
16	Number of patients who received transplants during this period						16
			HOME PROGRAM
17	Number of patients commencing home dialysis training during this period						17
18	Number of patients currently in home program						18
				1	2	3
19	Type of dialyzers used. If dialyzers are reused, indicate number of times (see instructions)						19
	RENAL DIALYSIS FACILITY--NUMBER OF EMPLOYEES
		(FULL TIME EQUIVALENTS)
Enter the number of hours in your normal work week				Staff	Contract	Total
				1	2	3
20	Physicians						20
21	Registered Nurses						21
22	Licensed Practical Nurses						22
23	Nurses Aides						23
24	Technicians						24
25	Social Workers						25
26	Dieticians						26
27	Administrative						27
28	Management						28
29	Other (Specify)						29
FORM CMS 265-94 (3-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II SECTION 3405
34-304							Rev. 7

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Sheet 5: ws-A

03-05				Form CMS-265-94							3490 (Cont.)
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE				FACILITY NO.:		REPORTING PERIOD			WORKSHEET A
OF EXPENSES						FROM:_______________________
				_________________		TO:____________________
							RECLASS.	RECLASSIFIED	ADJUSTMENTS	NET EXPENSES
			SALARIES				TO EXPENSES	TRIAL BALANCE	TO EXPENSES	FOR COST
		FACILITY HEALTH CARE COSTS	PHYSICIAN			TOTAL	(FROM	(COL.4	(FROM	ALLOCATION
			COMPENSATION	OTHER	OTHER	(COL.1-COL.3)	WKST.A-1)	+/- COL.5)	(WKST. A-2)	(COL.6+/-COL.7)
			1	2	3	4	5	6	7	8
		COST CENTERS
1	0100	Capital-Related--Buildings and Fixtures									1
2	0200	Capital-Related--Moveable Equipment									2
3	0300	Operation and Maintenance of Plant									3
4	0400	Housekeeping									4
5*		Subtotal (sum of lines 1-4)									5*
6*	0600	Machine Capital-Related or Rental and Maintenance									6*
7*	0700	Salaries for Direct Patient Care									7*
8*	0800	Emp. Health & Welfare Benefits for Direct Patient Care									8*
9*	0900	Drugs									9*
10*	1000	Supplies									10*
11*	1100	Laboratory									11*
12	1200	Administrative and General									12
13	1300	Interest Expense								-0-	13
14	1400	Laundry and Linen									14
15	1500	Medical Records									15
16	1600	Physicians' Routine Professional Services-Initial Method									16
17	1700	Other (Specify)									17
18*		Subtotal(sum of lines 12-17)									18*
19	1900	Physicians' Routine Professional Services-MCP Method							( )	-0-	19
20*	2000	Whole Blood and Packed Red Blood Cells									20*
21*	2100	Hepatitis B Vaccine									21*
		NONREIMBURSABLE COSTS CENTERS
22*	2200	Physicians' Private Offices									22*
23	2300	Epoetin								-0-	23
24*	2400	Method II Patients (Direct Dealing)									24*
25*	2500	Other Nonreimbursable (Specify)									25*
26*	2600	Other Nonreimbursable (Specify)									26*
27		Total					-0-				27
* Transfer the amounts in column 8 to Worksheet B and B-1, as appropriate.
FORM CMS-265-94 (3-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3406)
Rev. 7											34-305

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Sheet 6: ws-A-1

3490 (Cont.)			Form CMS-265-94						03-05
RECLASSIFICATIONS		FACILITY NO.:			REPORTING PERIOD:		WORKSHEET A-1
					FROM:___________________
		_______________________			TO:____________________
		CODE	INCREASE			DECREASE
			COST	LINE		COST	LINE
	EXPLANATION OF ENTRY	(1)	CENTER	NO.	AMOUNT (2)	CENTER	NO.	AMOUNT (2)
		1	2	3	4	5	6	7
1									1
2									2
3									3
4									4
5									5
6									6
7									7
8									8
9									9
10									10
11									11
12									12
13									13
14									14
15									15
16									16
17									17
18									18
19									19
20									20
21									21
22									22
23									23
24									24
25									25
26									26
27									27
28									28
29									29
30									30
31									31
32									32
33									33
34									34
35									35
36	TOTAL RECLASSIFICATIONS (Sum of Column 4								36
	must equal sum of Column 7)
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.
(2) Transfer to Worksheet A, Col 5, line as appropriate.
FORM CMS-265-94 (9-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3407)
34-306									Rev. 7

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Sheet 7: ws-A-2

04-02				Form CMS-265-94					3490 (Cont.)
ADJUSTMENTS TO EXPENSES		FACILITY NO.:			REPORTING PERIOD:		WORKSHEET A-2
					FROM:_____________
		___________________			TO:____________
		Basis for			Expense Classification on Worksheet A
		Adjust-			from which amount is to be deducted
	Description (1)	ment			or to which the amount is to be added
		(2)		Amount	Cost Center			Line No.
		1		2	3			4
1	Investment Income on Commingled								1
	Restricted and Unrestricted Funds
	(chapter 2)
2	Trade, Quantity and Time Discounts								2
	on Purchases (chapter 8)		B			Administrative & General		12
3	Rebates and Refunds of								3
	Expenses (chapter 8)
4	Rental of Building or Office								4
	Space to Others
5	Physician Non Routine Professional								5
	Patient Care Services
6	Home Office Costs								6
	(chapter 21)
7	Adjustment Resulting From Transactions	From							7
	With Related Organizations	Wkst.
	(chapter 10)	A-3
8	Vending Machines								8
9	Meals Served to Patients								9
10	Physicians' Professional								10
	Services--MCP Method							19
11	Services Under Arrangement								11
12	Provision for Doubtful Accounts								12
13	Capital Related -Buildings & Fixtures					Capital-Related		1	13
14	Capital Related -Moveable Equipment					Capital-Related		2	14
15	Rebates on Epoetin					Epoetin		23	15
16	Epoetin					Epoetin		23	16
17	Other (Specify)								17
18	Other (Specify)								18
19	Other (Specify)								19
20	Other (Specify)								20
21	Total Transfer to Wkst. A								21
	col.7, line 27
	(1) Description-all chapter references in this column pertain to CMS Pub. 15-II
	(2) Basis for adjustment (SEE INSTRUCTIONS)
	A. Costs-if cost, including applicable overhead, can be determined
	B. Amount Received-if cost cannot be determined
	FORM CMS-265-94 (8/95) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS
	PUB 15-II, SECTION 3408)
Rev. 6									34-307

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Sheet 8: ws-A-3

3490 (Cont.)

Form CMS-265-94

04-02

STATEMENT OF COSTS OF SERVICES

FACILITY NO.:

REPORTING PERIOD:

WORKSHEET A-3

FROM RELATED ORGANIZATIONS

FROM__________________

____________________

TO_________________

A.

Are there any costs included on Worksheet A which resulted from transactions with related organizations as

defined in the Provider Reimbursement Manual, Part I, Chapter 10?

[ ] Yes

[ ] No (If "Yes", complete Parts II and III )

B.

Costs incurred and adjustments required as result of transactions with related organizations:

AMOUNT

NET

LOCATION AND AMOUNT INCLUDED ON WORKSHEET A, COLUMN 6

ALLOWABLE

ADJUSTMENT

IN COST

(COL.4 MINUS

LINE NO.

COST CENTER

EXPENSES ITEMS

AMOUNT

COL. 5)

1

2

3

4

5

6

1

1

2

2

3

3

4

4

5

TOTALS (sum of lines 1-4) Transfer col.6, line 1-4 to Wkst. A,col.7 as appropriate)

5

(Transfer col.6, line 5 to Wkst. A-2, col.2, line 7, Adjustment to Expenses)

C.

Interrelationship of facility to related organization (s):

The Secretary, by virtue of the authority granted under section 1814(b)(1) of the Social Security Act,

requires the provider to furnish the information requested on Part C of this worksheet.

This information will be used by the Centers for Medicare and Medicaid Services and its intermediaries in determining

that the costs applicable to services, facilities, and supplies furnished by organizations related to the facility by

common ownership or control, represent reasonable costs as determined under section 1861(v) (1) (a) of the Social

Security Act. If the provider does not provide all or any part of the requested information, the cost report is considered

incomplete and not acceptable for purposes of claiming reimbursement under title XVIII.

RELATED ORGANIZATION (S)

Percentage

Percentage

SYMBOL

of

of

Type of

(1)

Name

Ownership

Name

Ownership

Business

1

2

3

4

5

6

1

1

2

2

3

3

4

4

(1) Use the following symbols to indicate interrelationship to related organizations:

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

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

C. Facility has financial interest in corporation, partnership, or other organization(s);

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

in related organization;

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

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

financial interest in the facility;

G. Other (financial or non-financial) specify _____________________________

FORM CMS-265-94(9/94) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,Section 3409)

34-308

Rev. 6

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Sheet 9: ws-A-4^

12-05				Form CMS-265-94					3490 (Cont.)
PART 1. STATEMENT OF TOTAL COMPENSATION TO				FACILITY NO.:		REPORTING PERIOD:		WORKSHEET A-4
OWNERS. (INCLUDE COMPENSATION OF						FROM_______________
EMPLOYEES RELATED TO OWNER)
				___________________		TO_______________
			SOLE PRO-			CORPORATION
	TITLE	FUNCTION	PRIETOR-	PARTNERS		OWNERS
		(A)	SHIPS					TOTAL
			PERCENTAGE		PERCENTAGE		PERCENTAGE	COMPENSATION
			OF	PERCENT	OF	PERCENT	OF	INCLUDED IN
			CUSTOMARY	SHARE OF	CUSTOMARY	OF	CUSTOMARY	ALLOWABLE
			WORK WEEK	OPERATING	WORK WEEK	PROVIDER'S	WORK WEEK	COSTS FOR
			DEVOTED TO	PROFIT	DEVOTED TO	STOCK	DEVOTED TO	THE PERIOD
			BUSINESS	OR(LOSS)	BUSINESS	OWNED	BUSINESS	(B)
	(1)	(2)	(3)	(4a)	(4b)	(5a)	(5b)	(6)
1									1
2									2
3									3
4									4
5									5
6									6
7									7
8									8
9									9
10									10
(A) Fully describe function or job description of each owner on reverse side of this page or a separate page
	(If employee is related to owner, site relationship.)
(B) Compensation as used in this worksheet has the same definition as CFR 413.102
PART II. STATEMENT OF TOTAL COMPENSATION TO ADMINISTRATORS, ASSISTANT ADMINISTRATORS
AND/OR MEDICAL DIRECTORS OR OTHERS PERFORMING THESE DUTIES(OTHER THAN OWNERS)
			TO BE COMPLETED BY ALL FACILITIES
				PERCENTAGE OF CUSTOMARY
				WORK WEEK DEVOTED			TOTAL COMPENSATION
		TITLE		TO BUSINESS			FOR THE PERIOD
1									1
2									2
3									3
4									4
5									5
6									6
7									7
8									8
9									9
10									10
FORM CMS-265-94 (9/94) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3410)
Rev. 9									34-309

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Sheet 10: ws-B^

3490 (Cont.)

Form CMS-265-94

12-05

COST ALLOCATION-GENERAL SERVICE COSTS

FACILITY NO.:

REPORTING PERIOD

WORKSHEET B

FROM

TO

NET

CAP. RELATED

EMPLOYEE

TOTAL

EXPENSES

OPERATION

SALARIES

HEALTH &

EXPENSES

FOR COST

AND MAINT.

MACHINE

FOR

WELFARE

SUBTOTAL

A & G

ALL

ALLOCATION

OF PLANT

CAP. RELATED

DIRECT

BENEFITS

DRUGS

SUPPLIES

LABORATORY

(COLS.1-8)

& OTHER

PATIENT

(FROM

AND

OR RENTAL

PATIENT

FOR DIRECT

COST

SERVICES

WKST. A,

HOUSE

AND MAINT.

CARE

PATIENT

CENTERS

(COLS.

COL.8)

KEEPING

CARE

9 & 10)

1

2

3

4

5

6

7

8

9

10

11

1

COSTS TO BE ALLOCATED

1

2

Separately Billable Drugs

2

3

Separately Billable Supplies

3

4

Separately Billable

4

Laboratory Services

5

Whole Blood and Packed

5

Red Blood Cells

6

Hepatitis B Vaccine

6

REIMBURSABLE

COST CENTERS

7*

Maintenance-Hemodialysis

7*

8*

Maintenance

8*

Peritoneal Dialysis

9*

Training-Hemodialysis

9*

10*

Training-Peritoneal Dialysis

10*

11*

Training-CAPD

11*

12*

Training-CCPD

12*

13*

Home Program-Hemodialysis

13*

14*

Home Program-

14*

Peritoneal Dialysis

15*

Home Program-CAPD

15*

16*

Home Program-CCPD

16*

16.01

Subtotal (sum oflines 1-16)

16.01

NONREIMBURSABLE

COST CENTERS

17

Physicians' Private Offices

17

18

Method II Patients

18

19

19

20

20

21

Totals (see instructions)

21

*Transfer the amounts to Worksheet C, column 2, as appropriate

The total of column 1, line 21 must equal the amount on Worksheet A, column 8, line 27.

FORM CMS-265-94 (12-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3411)

34-310

Rev. 9

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Sheet 11: ws-B-1^

12-05					Form CMS-265-94								3490 (Cont.)
COST ALLOCATION-STATISTICAL BASIS					FACILITY NO.:			REPORTING PERIOD:			WORKSHEET B-1
								FROM________________
					___________________			TO_______________
			CAP. RELATED			EMPLOYEE
			OPERATION		SALARIES	HEALTH &
	COST CENTERS		AND MAINT.	MACHINE	FOR	WELFARE					UNIT
			OF PLANT	CAP. RELATED	DIRECT	BENEFITS	DRUGS	SUPPLIES	LABORATORY		COST
			AND	OR RENTAL	PATIENT	FOR DIRECT					MULTIPLIER
			HOUSE	AND MAINT.	CARE	PATIENT					COMPUTATION
				(% OF	(HRS. OF	(GROSS
			(SQ. FEET)	TIME SPENT)	SERVICE)	SALARIES)	(CHARGES)	(CHARGES)	(CHARGES)
		1	2	3	4	5	6	7	8	9	10	11
1	COSTS TO BE ALLOCATED												1
2	Separately Billable Drugs												2
3	Separately Billable Supplies												3
4	Separately Billable												4
	Laboratory Services
5	Whole Blood and Packed												5
	Red Blood Cells
6	Hepatitis B Vaccine												6
	REIMBURSABLE
	COST CENTERS
7	Maintenance-Hemodialysis												7
8	Maintenance												8
	Peritoneal Dialysis
9	Training-Hemodialysis												9
10	Training-Peritoneal Dialysis												10
11	Training-CAPD												11
12	Training-CCPD												12
13	Home Program-Hemodialysis												13
14	Home Program-												14
	Peritoneal Dialysis
15	Home Program-CAPD												15
16	Home Program-CCPD												16
	NONREIMBURSABLE
	COST CENTERS
17	Physicians' Private Offices												17
18	Method II Patients												18
19													19
20													20
21	Total (SEE INSTRUCTIONS)												21
22	Total Costs to be Allocated												22
23	Unit Cost Multiplier (22/21)												23
FORM CMS-265-94 (2/95) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3411)
Rev. 9													34-311

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Sheet 12: ws-C^

3490 (Cont.)				Form CMS-265-94							12-05
COMPUTATION OF AVERAGE COST				FACILITY NO.:		REPORTING PERIOD			WORKSHEET C
	PER TREATMENT					FROM_______________
				_________________		TO_______________
			TOTAL				MEDICARE
					NUMBER OF	NUMBER OF		PAYMENT	PAYMENT
		NUMBER	COSTS	AVERAGE COST	TREATMENTS	TREATMENTS	TOTAL	RATE	RATE	TOTAL
		OF	(TRANSFERRED FROM	OF TREATMENTS	(Pre 4/1/2005,	(Post 4/1/2005,	EXPENSES	(Pre 4/1/2005,	(Post 4/1/2005,	PAYMENT DUE
		TREATMENTS	WKST. B., COL.11)	(COL.2/COL.1)	see instructions)	see instructions)	(COL.4 x COL.3)	see instructions)	see instructions)	(COL.4 x COL.6)
		1	2	3	4	4.01	5	6	6.01	7
			Line 7
1	Maintenance-Hemodialysis										1
			Line 8
2	Maintenance-Peritoneal Dialysis										2
			Line 9
3	Training-Hemodialysis										3
			Line 10
4	Training-Peritoneal Dialysis										4
			Line 11
5	Training-CAPD										5
			Line 12
6	Training-CCPD										6
			Line 13
7	Home Program-Hemodialysis										7
			Line 14
8	Home Program-Peritoneal Dialysis										8
		Patient Wks	Line 15
9	Home Program-CAPD										9
		Patient Wks	Line 16
10	Home Program-CCPD										10
11	Totals Sum of Lines 1-8 (Cols. 1 & 4)										11
	Sum of Lines 1-10 (Cols. 2,5, & 7)
FORM CMS-265-94 (12-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3412)
34-312											Rev. 9

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Sheet 13: ws-D^

12-05		Form CMS-265-94			3490 (Cont.)
CALCULATION OF REIMBURSABLE		FACILITY NO.	PERIOD:
BAD DEBTS TITLE XVIII-PART B			FROM:______________	WORKSHEET D
			TO:______________
1	Total Expenses Related to Care of Medicare Beneficiaries				1
	(From Worksheet C, Column 5, line 11)
2	Total Payment Due (Net of Part B Deductibles)				2
	(From Worksheet C, Column 7, line 11)
3	Program Payments(80% of Line 2)				3
4	Amount of Cost To Be Recovered From Medicare				4
	Patients (Line 1 Minus Line 3)
5	Deductibles and Coinsurance Billed to Medicare				5
	(Part B) Patients
6	Bad Debts for Deductibles and Coinsurance, Net				6
	of Bad Debt Recoveries
7	Net Deductibles and Coinsurance Billed to				7
	Medicare (Part B) Patients (Line 5 Minus Line 6)
	Unrecovered From Medicare (Part B) Patients (Line 4
8	Minus Line 7)( If Line 7 Exceeds Line 4, Do Not				8
	Complete Line 9)
9	Reimbursable Bad Debts(Lessor of Line 6 or Line 8)				9
9.01	Reimbursable bad debts for dual eligible beneficiaries (see				9.01
	instructions)
FORM CMS 265-94 (12-2005) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,
SECTION 3413)
Rev. 9					34-313