Form CMS-1728-94 Medicare Cost Report Forms

Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106

R15P232f.xlsx

Home Health Agency Cost Report and Supporting Regulations in 42 CFR 413.20, 413.24, 413.106

OMB: 0938-0022

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Overview

S
S-2
S-3
S-3, Pt IV
S-4
S-5
S-6
A
A-1
A-3
A-2
A-4
A-5
A-6
A-7
A83-1
A83-2
B,B-1
C
D
D-1
F
F-1
F-2
J-1 & J-2
J-1, PT3
J-3
J-4
K
K-1
K-2
K-3
K-4I
K-4II
K-5I
K-5II
K-5III
K-6
CM-1 & CM-2
CM-1, PT3
CM-3
CM-4
RHC
RH-1, PT3
FQHC
FQ-1, PT3
RF-1
RF-2
RF-3
RF-4
RF-5


Sheet 1: S

01-10


FORM CMS 1728-94



3290 (Cont.)
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result








in all interim payments made since the beginning of the cost reporting period being deemed





FORM APPROVED

as overpayments (42 USC 1395g).





OMB NO. 0938-0022

HOME HEALTH AGENCY COST REPORT


PROVIDER NO.:
PERIOD:


CERTIFICATION AND SETTLEMENT SUMMARY




From: ___________
WORKSHEET S




_______________
To: ___________



Intermediary Use Only:


















[ ] Audited Date Received
____________ [ ] Initial
[ ] Re-opened

[ ] Desk Reviewed Intermediary No.
____________ [ ] Final












PART I - CERTIFICATION


















Check
[ ] Electronically filed cost report

Date: ___________


applicable box
[ ] Manually submitted cost report

Time: ___________


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 DIRECTOR OF THE AGENCY
















I HEREBY CERTIFY that I have read the above statement and that I have examined the accompanying








Home Health Agency Cost Report and the Balance Sheet and Statement of Revenue and Expenses








prepared by _________________________________________(Provider name(s) and number(s)) for the cost








report beginning _____________________and ending __________________________, and that to the








best of my knowledge and belief, it is a true, correct and complete report 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 regulations.



















(Signed) __________________________________________








Officer or Director








__________________________________________








Title








__________________________________________








Date



































PART II - SETTLEMENT SUMMARY























TITLE XVIII







PART A

PART B




1

2










1 HOME HEALTH AGENCY






1










2 HOME HEALTH-BASED CORF






2










3 HOME HEALTH-BASED CMHC






3
3.5 HOME HEALTH-BASED RHC/FQHC






3.5

(specify)

















4 TOTAL






4










"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 0938-0022. The time required to complete this








information collection is estimated to average 226 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 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 Reports Clearance Officer, Mail








Stop C4-26-05, Baltimore, Maryland 21244-1850."




























FORM CMS-1728-94-S (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECS. 3203-3203.2)


















Rev. 14







32-303

Sheet 2: S-2

3290 (Cont.)












FORM CMS 1728-94












01-10
HOME HEALTH AGENCY COMPLEX










PROVIDER NO.:



PERIOD:










IDENTIFICATION DATA















From: ___________




WORKSHEET S-2
















________________



To: ___________







































Home Health Agency Complex Address:



























1
Street:












P.O. Box:










1
1.01
City:






State:




Zip Code:










1.01





























Home Health Agency Component Identification

























































Component Component Name Provider No. Date Certified




0






1





2




3


2
Home Health Agency
























2
3
HHA-based CORF
























3
3.50
HHA-based Hospice
























3.50
4
HHA-based CMHC
























4
5
HHA- based RHC
























5
6
HHA-based FQHC
























6





























7 Cost Reporting Period (mm/dd/yyyy)












From: ______________






To: ______________



7





























8 Type of control (see instructions)

























8





























9 If this a low or no Medicare utilization cost report,

























9

enter "L" for Low or "N" for No Medicare Utilization.























































Depreciation: Enter the amount of depreciation reported in this HHA for the methods indicated.



























10 Straight Line

























10
11 Declining Balance

























11
12 Sum of the Years' Digits

























12
13 Sum of lines 10, 11 and 12

























13





























14 Were there any disposals of capital assets during this cost reporting period?

























14
15 Was accelerated depreciation claimed on any assets in the current or any prior cost reporting period?

























15
16 Was accelerated depreciation claimed on assets acquired on or after August l, l970 (See PRM 15-1,

























16

Chapter l)?


























17 If depreciation is funded, enter the balance at end of period.

























17
18 Did the provider cease to participate in the Medicare program at the end of

























18

the period to which this cost report applies (See PRM 15-1, Chapter 1)?


























19 Was there substantial decrease in health insurance proportion of allowable

























19

costs from prior cost reporting periods (See PRM 15-1, Chapter 1)?


























20 Does the provider qualify as a small HHA (defined in 42 CFR 413.24(d))?

























20
21 Does the home health agency qualify as a nominal charge provider (defined in 42 CFR 409.3)?

























21
22 Does the home health agency contract with outside suppliers for physical therapy services?

























22
22.01 Does the home health agency contract with outside suppliers for occupational therapy services?

























22.01
22.02 Does the home health agency contract with outside suppliers for speech therapy services?

























22.02





























If this facility contains a non-public 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 the exemption.

















































Part A

Part B
























1

2

23 Home Health Agency

























23
24 CORF

























24
25 CMHC

























25
26 If the home health agency componentized (or fragmented) its administrative and general service

























26

costs, indicate whether option one or option two is being utilized. (See PRM-II, Section 3214)



























(Enter "1" for option one and "2" for option two)























































27 List amounts of malpractice premiums and paid losses:

























27
27.01 Premiums

























27.01
27.02 Paid Losses

























27.02
27.03 Self Insurance

























27.03
28 Are malpractice premiums and/or paid losses reported in other than the Administrative and General

























28

cost center? If yes, submit a supporting schedule listing cost centers and amounts contained therein.


























29 If you are part of a chain organization, enter "Y" for yes and enter the name and address of the home

























29

office, otherwise, enter "N" for no.


























29.01 Home Office Name:








Home Office No. :






FI/Contractor No. :







29.01
29.02 Street:








P.O. Box:



FI/MAC Name:










29.02
29.03 City:







State:




Zip Code:










29.03





























FORM CMS 1728-94-S-2 (1-2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3204)
























































32-304


























Rev. 14

Sheet 3: S-3

05-07



FORM CMS 1728-94



3290 (Cont.)
HOME HEALTH AGENCY



PROVIDER NO.:
PERIOD:
WORKSHEET S-3
STATISTICAL DATA





From: ___________
PARTS I - III





______________
To: ___________













PART I - STATISTICAL DATA




COUNTY Cook

















Title XVIII Other Total

DESCRIPTION

Visits Patients Visits Patients Visits Patients




1 2 3 4 5 6
1 Skilled Nursing







1
2 Physical Therapy







2
3 Occupational Therapy







3
4 Speech Pathology







4
5 Medical Social Service







5
6 Home Health Aide







6
7 All Other Services







7
8 Total Visits







8
9 Home Health Aide Hours







9
10 Unduplicated Census Count -







10

Full Cost Reporting Period








10.01 Unduplicated Census Count -







10.01

Pre 10/1/2000








10.02 Unduplicated Census Count -







10.02

Post 9/30/2000



















PART II - EMPLOYMENT DATA









(FULL TIME EQUIVALENT)





















Number of hours in









your normal work week __________




Staff Contract Total







1 2 3
11 Administrator and Assistant Administrator(s)







11
12 Director and Assistant Director(s)







12
13 Other Administrative Personnel







13
14 Direct Nursing Service







14
15 Nursing Supervisor







15
16 Physical Therapy Service







16
17 Physical Therapy Supervisor







17
18 Occupational Therapy Service







18
19 Occupational Therapy Supervisor







19
20 Speech Pathology Service







20
21 Speech Pathology Supervisor







21
22 Medical Social Service







22
23 Medical Social Supervisor







23
24 Home Health Aide







24
25 Home Health Aide Supervisor







25
26








26
27








27











PART III - METROPOLITAN STATISTICAL AREA (MSA) AND CORE BASED STATISTICAL AREA (CBSA) CODES

















1 1.01

Enter the total number of MSAs in column 1 and/or CBSAs in column 2 where Medicare








28 covered services were provided during the cost reporting period.







28

List all MSA and CBSA codes in which Medicare covered home health services were





MSA Codes CBSA Codes
29 provided during the cost reporting period (line 29 contains the first code):







29










29.01










29.02










29.03










29.04










29.05










29.06










29.07










29.08










29.09
FORM CMS-1728-94 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,









SEC. 3205)




















Rev. 13








32-305

Sheet 4: S-3, Pt IV

3290 (Cont.)



FORM CMS 1728-94



05-07
HOME HEALTH AGENCY



PROVIDER NO.:
PERIOD:
WORKSHEET S-3
STATISTICAL DATA





From: ______________
PART IV





______________
To: ______________













PART IV - PPS ACTIVITY DATA - Applicable for Services Rendered on or After October 1, 2000





Cook
















Full Episodes Full Episodes LUPA Episodes PEP Only SCIC within a SCIC Only Totals

DESCRIPTION
without Outliers with Outliers
Episodes PEP Episodes




1 2 3 4 5 6 7
30 Skilled Nursing Visits







30
31 Skilled Nursing Visit Charges







31
32 Physical Therapy Visits







32
33 Physical Therapy Visit Charges







33
34 Occupational Therapy Visits







34
35 Occupational Therapy Visit Charges







35
36 Speech Pathology Visits







36
37 Speech Pathology Visit Charges







37
38 Medical Social Service Visits







38
39 Medical Social Service Visit Charges







39
40 Home Health Aide Visits







40
41 Home Health Aide Visit Charges







41
42 Total Visits (Sum of lines 30,32,34,36,38,40)







42
43 Other Charges







43
44 Total Charges (Sum of lines 31,33,35,37,39,41,43)







44
45 Total Number of Episodes







45
46 Total Number of Outlier Episodes







46
47 Total Non-Routine Medical Supply Charges







47






































































































































































































FORM CMS-1728-94 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3205)




















32-305.1








Rev. 13

Sheet 5: S-4

06-01






FORM CMS 1728-94







3290 (Cont.)
HHA-BASED RURAL HEALTH CLINIC/






PROVIDER NO.:


PERIOD:

WORKSHEET S-4

FEDERALLY QUALIFIED HEALTH CENTER






_____________


FROM: __________




PROVIDER STATISTICAL DATA






COMPONENT NO.:


TO: ___________












_____________








Check

[ ] RHC













Applicable Box

[ ] FQHC































Clinic Address and Identification:
















1 Street:














1
1.01 City:





State:


Zip Code:
County:

1.01
2 Designation (for FQHCs only) - Enter "R" for rural or "U" for urban














2


















Source of Federal Funds:











Grant Award Date













1 2
3 Community Health Center (Section 330(d), PHS Act)














3
4 Migrant Health Center (Section 329(d), PHS Act)














4
5 Health Services for the Homeless (Section 340(d), PHS Act)














5
6 Appalachian Regional Commission














6
7 Look-Alikes














7
8 Other (specify)














8


















Physician Information:











Physician Billing













Name Number
9 Physician(s) furnishing services at the clinic or under agreement (see instructions)














9































Physician Hours of













Name Supervision
10 Supervisory physician(s) and hours of supervision during period (see instructions)














10


















11 Does the facility operate as other than an RHC or FQHC? If yes, indicate number of other operations in column 2 and














11

list the other type(s) of operation(s) and hours on subscripts of line 12.


































Enter the clinic hours on line 12 and list the other type(s) of operation(s) and hours on subscripts of line 12. (1)


















Sunday Monday Tuesday Wednesday Thursday Friday Saturday



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
12 Clinic














12
12.01 Specify:














12.01
12.02 Specify:














12.02
12.03 Specify:














12.03



















(1) List hours of operation based on a 24 hour clock. For example, 8:30am is 0830, 5:30pm is 1730 and 12 midnight is 2400.

































13 Has the facility been approved for an exception to the productivity standard?














13
14 Is this a consolidated cost report as defined in CMS Pub. 27, section 508(D)? If yes, enter in column 2 the














14

number of providers included in this report. List all provider names and numbers below.















15 Provider name: ______________________________






Provider number: _______________






15
15.01 Provider name: ______________________________






Provider number: _______________






15.01
15.02 Provider name: ______________________________






Provider number: _______________






15.02
15.03 Provider name: ______________________________






Provider number: _______________






15.03
16 Are you claiming allowable and/or non-allowable GME costs as a result of "substantial payment" for interns














16

and residents? If yes, enter the number of Medicare visits in column 2 performed by interns and residents
















and complete Worksheet RF-1, lines 20 and 27 as applicable.

















































































































































































































































































































































































































































































FORM CMS-1728-94-S4 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3233)


































Rev. 10















32-305.2

Sheet 6: S-5

3290 (Cont.)




FORM CMS-1728-94



06-01






PROVIDER NO.:
PERIOD:


HOSPICE IDENTIFICATION DATA




_____________
FROM: _____________
WORKSHEET S-5






HOSPICE NO.:
TO: ________________








_____________




























PART I

















Title XVIII
Total








Unduplicated
Unduplicated








Skilled Other Days







Unduplicated Nursing Unduplicated (sum of



Enrollment Days


Days Facility Days Days cols. 1 & 3)







1 2 3 4
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


















Title XVIII










Skilled
Total








Nursing
(sum of


Census Data



Title XVIII Facility Other cols. 1 & 3)







1 2 3 4
6 Number of Patients Receiving








6

Hospice Care









7 Total Number of Unduplicated








7

Continuous Care Hours










Billable to Medicare









8 Average Length of Stay (line 5 divided by line 6)








8
9 Unduplicated Census Count








9
























NOTE: Parts I & II, column 1 also includes the days reported in column 2.










































































































































































































































































































FORM CMS-1728-94-S-5 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB 15-II,










SECTIONS 3239 - 3239.2)










32-306









Rev. 10

Sheet 7: S-6

05-07





























FORM CMS 1728-94






















3290 (Cont.)
HHA-BASED CORF STATISTICAL DATA















PROVIDER NO.: _______________














PERIOD:














SUPPLEMENTAL






















CORF NO.: _______________














From: ___________












WORKSHEET S-6





































To: ___________





















CORF TREATMENTS



























Title XVIII Other Total































Treatments Patients Treatments Patients Treatments Patients































1 2 3 4 5 6
1 Skilled Nursing Care




















































1
2 Physical Therapy




















































2
3 Occupational Therapy




















































3
4 Speech Pathology




















































4
5 Medical Social Services




















































5
6 Respiratory Therapy




















































6
7 Psychological Services




















































7
8 All Other Service




















































8
9 Total Treatments (Sum of lines 1-8)




















































9

CORF - NUMBER OF EMPLOYEES ( FULL TIME EQUIVALENT )



























































Enter the number of hours






















































in your normal workweek __________


























Staff






Contract






Total






































1







2





3




10 Administrators and Assistant Administrators




















































10
11 Directors and Assistant Directors




















































11
12 Other Administrative Personnel




















































12
13 Direct Nursing Service




















































13
14 Nursing Supervisor




















































14
15 Physical Therapy Service




















































15
16 Physical Therapy Supervisor




















































16
17 Occupational Therapy Service




















































17
18 Occupational Therapy Supervisor




















































18
19 Speech Pathology Service




















































19
20 Speech Pathology Supervisor




















































20
21 Medical Social Service




















































21
22 Medical Social Supervisor




















































22
23 Respiratory Therapy Service




















































23
24 Respiratory Therapy Supervisor




















































24
25 Psychological Service




















































25
26 Psychological Service Supervisor




















































26
27





















































27
28





















































28
























































































































































































































































































































































































































































































































































































































































































































































FORM CMS 1728-94-S-6 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3220)














































































































Rev. 13





















































32-307

Sheet 8: A

3290 (Cont.)






FORM CMS 1728-94





05-07










PROVIDER NO.:
PERIOD:




RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES






_______________
From: ___________
WORKSHEET A











To: ___________










CONTRACTED


RECLASSI-
EXPENSES






EMPLOYEE TRANSPOR- PURCHASED

RECLASSI- FIED TRIAL
FOR COST





SALARIES BENEFITS TATION (See SERVICES OTHER
FICATION BALANCE ADJUST- ALLOCATION





(Fr Wks A-1) (Fr Wks A-2) Instructions) (Fr Wks A-3) COSTS TOTAL (Fr Wks A-4) (Cols 6 + 7) MENTS (Col 8 + 9)





1 2 3 4 5 6 7 8 9 10


GENERAL SERVICE COST CENTER












1 0100 Capital Related - Bldg. & Fix.











1
2 0200 Capital Related - Movable Equip











2
3 0300 Plant Operation & Maintenance











3
4 0400 Transportation (See Instructions)











4
5 0500 Administrative and General











5


HHA REIMBURSABLE SERVICES












6 0600 Skilled Nursing Care











6
7 0700 Physical Therapy











7
8 0800 Occupational Therapy











8
9 0900 Speech Pathology











9
10 1000 Medical Social Services











10
11 1100 Home Health Aide











11
12 1200 Supplies (See Instructions)











12
13 1300 Drugs











13
13.20 1320 Cost of Administering Vaccines











13.20
14 1400 DME











14


HHA NONREIMBURSABLE SERVICES












15 1500 Home Dialysis Aide Services











15
16 1600 Respiratory Therapy











16
17 1700 Private Duty Nursing











17
18 1800 Clinic











18
19 1900 Health Promotion Activities











19
20 2000 Day Care Program











20
21 2100 Home Delivered Meals Program











21
22 2200 Homemaker











22
23
Other











23


SPECIAL PURPOSE COST CENTERS












24 2400 CORF











24
25 2500 Hospice











25
26 2600 CMHC











26
27 2700 RHC











27
28 2800 FQHC











28
29
Total











29
FORM CMS-1728-94 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3206)






























32-308













Rev. 13

Sheet 9: A-1

08-99





FORM CMS 1728-94




3290 (Cont.)
COMPENSATION ANALYSIS






PROVIDER NO.:
PERIOD:


SALARIES AND WAGES






_______________
From: ___________
WORKSHEET A-1









To: ___________






ADMINIS-





ALL TOTAL




TRATORS DIRECTORS CONSULTANTS SUPERVISORS NURSES THERAPISTS AIDES OTHER (1)




1 2 3 4 5 6 7 8 9

GENERAL SERVICE COST CENTER











1 Capital Related - Bldg. and Fixtures










1
2 Capital Related - Movable Equipment










2
3 Plant Operation & Maintenance










3
4 Transportation (See Instructions)










4
5 Administrative and General










5

HHA REIMBURSABLE SERVICES











6 Skilled Nursing Care










6
7 Physical Therapy










7
8 Occupational Therapy










8
9 Speech Pathology










9
10 Medical Social Services










10
11 Home Health Aide










11
12 Supplies










12
13 Drugs










13
14 DME










14

HHA NONREIMBURSABLE SERVICES











15 Home Dialysis Aide Services










15
16 Respiratory Therapy










16
17 Private Duty Nursing










17
18 Clinic










18
19 Health Promotion Activities










19
20 Day Care Program










20
21 Home Delivered Meals Program










21
22 Homemaker Service










22
23 Other










23

SPECIAL PURPOSE COST CENTERS











24 CORF










24
25 Hospice










25
26 CMHC










26
27 RHC










27
28 FQHC










28
29 Total










29


(1) Transfer the amounts in column 9 to Wkst. A, column 1
























FORM CMS-1728-94-A-1 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3207)


























Rev. 7











32-309

Sheet 10: A-3

08-99





FORM CMS 1728-94




3290 (Cont.)
COMPENSATION ANALYSIS






PROVIDER NO.:
PERIOD:


CONTRACTED SERVICES/PURCHASED SERVICES






_______________
From: ___________
WORKSHEET A-3










To: ___________






ADMINIS-





ALL TOTAL




TRATORS DIRECTORS CONSULTANTS SUPERVISORS NURSES THERAPISTS AIDES OTHER (1)




1 2 3 4 5 6 7 8 9

GENERAL SERVICE COST CENTER











1 Capital Related - Bldg. and Fixtures










1
2 Capital Related - Movable Equipment










2
3 Plant Operation & Maintenance










3
4 Transportation (See Instructions)










4
5 Administrative and General










5

HHA REIMBURSABLE SERVICES











6 Skilled Nursing Care










6
7 Physical Therapy










7
8 Occupational Therapy










8
9 Speech Pathology










9
10 Medical Social Services










10
11 Home Health Aide










11
12 Supplies










12
13 Drugs










13
14 DME










14

HHA NONREIMBURSABLE SERVICES











15 Home Dialysis Aide Services










15
16 Respiratory Therapy










16
17 Private Duty Nursing










17
18 Clinic










18
19 Health Promotion Activities










19
20 Day Care Program










20
21 Home Delivered Meals Program










21
22 Homemaker Services










22
23 Other










23

SPECIAL PURPOSE COST CENTERS











24 CORF










24
25 Hospice










25
26 CMHC










26
27 RHC










27
28 FQHC










28
29 Total










29
(1) Transfer the amounts in column 9 to Wkst. A, column 4


























FORM CMS-1728-94 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3209)


























Rev. 7











32-311

Sheet 11: A-2

3290 (Cont.)





FORM CMS 1728-94




08-99
COMPENSATION ANALYSIS






PROVIDER NO.:
PERIOD:


EMPLOYEE BENEFITS (PAYROLL RELATED)






_______________
From: ___________
WORKSHEET A-2










To: ___________






ADMINIS-





ALL TOTAL




TRATORS DIRECTORS CONSULTANTS SUPERVISORS NURSES THERAPISTS AIDES OTHER (1)




1 2 3 4 5 6 7 8 9

GENERAL SERVICE COST CENTER











1 Capital Related - Bldg. and Fixtures










1
2 Capital Related - Movable Equipment










2
3 Plant Operation & Maintenance










3
4 Transportation (See Instructions)










4
5 Administrative and General










5

HHA REIMBURSABLE SERVICES











6 Skilled Nursing Care










6
7 Physical Therapy










7
8 Occupational Therapy










8
9 Speech Pathology










9
10 Medical Social Services










10
11 Home Health Aide










11
12 Supplies










12
13 Drugs










13
14 DME










14

HHA NONREIMBURSABLE SRVS











15 Home Dialysis Aide Services










15
16 Respiratory Therapy










16
17 Private Duty Nursing










17
18 Clinic










18
19 Health Promotion Activities










19
20 Day Care Program










20
21 Home Delivered Meals Program










21
22 Homemaker Services










22
23 Other










23

SPECIAL PURPOSE COST CENTERS











24 CORF










24
25 Hospice










25
26 CMHC










26
27 RHC










27
28 FQHC










28
29 Total










29


(1) Transfer the amounts in column 9 to Wkst. A, column 2
























FORM CMS-1728-94-A-2 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3208)


























32-310











Rev. 7

Sheet 12: A-4

3290 (Cont.)






FORM CMS 1728-94




08-99









PROVIDER NO.
PERIOD:
WORKSHEET A-4



RECLASSIFICATIONS




_______________
From: ___________












To: ___________









CODE INCREASE

DECREASE



EXPLANATION OF RECLASSIFICATION ENTRY




(1) COST CENTER LINE NO. AMOUNT(2) COST CENTER LINE 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 TOTAL RECLASSIFICATIONS (Sum of col. 4 must equal sum of col. 7)











30
(1) A letter (A, B, etc.) must be entered on each line to identify each reclassification entry.













(2) Transfer to Worksheet A, column 7, line as appropriate.













FORM CMS-1728-94-A-4 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3210)




























32-312












Rev. 7

Sheet 13: A-5

08-99



FORM CMS 1728-94

3290 (Cont.)




PROVIDER NO.:
PERIOD:


ADJUSTMENTS TO EXPENSES

_______________
From: __________ WORKSHEET A-5






To: __________






Expense Classification on Worksheet A






To/From Which The Amount is to be Adjusted


Description (1)

(2)







BASIS/CODE Amount Cost Center Line No.




1 2 3 4
1 Excess funds generated from operations,

B (3,985) A&G Shared Costs 5.01 1

other than net income






2 Trade, quantity, time and other discounts

B


2

on purchases (Chap. 8)






3 Rebates and refunds of expenses (Chap. 8)

B


3
4 Home office costs (Chap. 21)

A 15,250 A&G Reimb. Costs 5.02 4
5 Adjustments resulting from transaction

From Wks #REF!

5

with related organization (Chap. 10)

A-6



6 Sale of medical records and abstracts

B


6
7 Income from imposition of interest,

B


7

finance or penalty charges (Chap. 21)






8 Sale of medical and surgical supplies to

A


8

other than patients






9 Sale of Drugs to other than patients

A


9
10 Physical therapy adjustment (Chap. 14)

From Supp


10




Wks A-8-3
Physical Therapy 7
10.1 Occupational therapy adjustment (Chap. 14)

From Supp


10.1




Wks A-8-3
Occupational Therapy 8
10.2 Speech pathology adjustment (Chap. 14)

From Supp


10.2




Wks A-8-3
Speech Pathology 9
11 Interest expense on Medicare overpayments and

A


11

borrowings to repay Medicare overpayments






12 Lobbying Activities

A (2,050) A&G Nonreimb. Costs 5.03 12









13






13









14






14









15






15









16






16









17






17









18






18









19






19









20






20









21 TOTAL (Sum of lines 1-20)


#REF!

21










(1) Description - All line references in this column pertain to the Provider







Reimbursement Manual, Part I.
















(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-1728-94-A-5 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3211)
















Rev. 7






32-313

Sheet 14: A-6

3290 (Cont.)




FORM CMS 1728-94


08-99
This report is required by law (42 USC 1395g; 42 CFR 413.20(b)). Failure to report can result









in all interim payments made since the beginning of the cost reporting period being deemed









as overpayments (42 USC 1395g).










STATEMENT OF COSTS OF



PROVIDER NO.:
PERIOD:
WORKSHEET A-6

SERVICES FROM





From: ___________


RELATED ORGANIZATIONS



____________
To: ___________

A. Are there any costs included on Worksheet A which resulted from transactions









with related organizations as defined in CMS Pub. 15-I, chapter 10?






















[ ] Yes [ ] No (If "Yes," complete Parts B and C)







B. Costs incurred and adjustment required as result of transactions with related organizations












LOCATION AND AMOUNT INCLUDED ON WKST A, COL. 8




AMOUNT NET









ALLOWABLE ADJUSTMENT

LINE NO. COST CENTER EXPENSE ITEMS AMOUNT IN COST (col 4 -5)

1 2 3 4 5 6
1









2








0
3








0
4 TOTALS (Sum of lines 1-3)(Transfer col. 6, lines 1-3 to Wkst A, Col. 9,









lines as appropriate)(Transfer col. 6, line 4 to Wkst A-5, col. 2, line 5)








C. Interrelationship of provider to related organization(s):




















The Secretary, by virtue of 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.




















The information will be used by the CMS and its intermediaries in determining that the costs applicable to services,









facilities and supplies furnished by organizations related to the provider by common ownership or control,









represent reasonable costs as determined under section 1861 of the Social Security Act.









If the provider does not provide all or any part of the requested information, the cost report will be considered









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







































Percent Percent








Owned Ownership
SYMBOL






by of Type of

(1) Name Address Provider Provider Business

1 2 3 4 5 6
1









2









3









4









5





















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





















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









B. Corporation, partnership or other organization has financial interest in provider.









C. Provider has financial interest in corporation, partnership or other organization.









D. Director, officer, administrator or key person of provider or relative of such person has financial interest in









related organization.









E. Individual is director, officer, administrator or key person of provider and related organization.









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









interest in provider.









G. Other (financial or nonfinancial) specify.
































































































































FORM CMS-1728-94-A-6 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3212)































32-314








Rev. 7

Sheet 15: A-7

08-99





FORM CMS 1728-94




3290 (Cont.)







PROVIDER NO.:
PERIOD:



ANALYSIS OF CHANGES IN CAPITAL ASSET BALANCE







From: ___________
WORKSHEET A-7








_______________
To: ___________














Disposals




Description


Beginning
Acquisitions
and Ending







Balances Purchases Donations Total Retirements Balance







1 2 3 4 5 6
1 Land










1
2 Land Improvements










2
3 Buildings and Fixtures










3
4 Building Improvements










4
5 Fixed Equipment










5
6 Movable Equipment










6
7 TOTAL










7






























































































































































































































































































































































FORM CMS-1728-94-A-7 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3213)


























Rev. 7











32-315

Sheet 16: A83-1

3290 (Cont.)




FORM CMS 1728-94




08-99
REASONABLE COST DETERMINATION FOR THERAPY





PROVIDER NO.:
PERIOD:
WORKSHEET A-8-3
SERVICES FURNISHED BY OUTSIDE SUPPLIERS







From: ___________
PARTS I - III







________________
To: ___________


Check applicable box:

[ ] Physical Therapy services rendered before 4/10/98 [ ] Occupational Therapy [ ] Speech Pathology











[ ] Physical Therapy services rendered on or after 4/10/98






















PART I - GENERAL INFORMATION










1 Total number of weeks worked (During which outside suppliers (excluding aides) worked)









1
2 Line 1 multiplied by 15 hours per week









2
3 Number of unduplicated HHA visits - supervisors or therapists (See Instructions)









3
4 Number of unduplicated HHA visits - therapy assistants (Include only visits made by therapy assistants and on which









4

supervisor and/or therapist was not present during the visit) (See Instructions)










5 Standard travel expense rate









5
6 Optional travel expense rate per mile









6








Supervisors Therapists Assistants Aides








1 2 3 4
7 Total hours worked









7
8 AHSEA (See Instructions)









8
9 Standard Travel Allowance (Cols 1 and 2, one-half of col 2, line 8; col 3, one-half of col 3, line 8)









9
10 Number of travel hours (HHA only)









10
11 Number of miles driven (HHA only)









11














PART II - SALARY EQUIVALENCY COMPUTATIONS










12 Supervisors (Col 1, line 7 times col 1, line 8)









12
13 Therapists (Col 2, line 7 times col 2, line 8)









13
14 Assistants (Col 3, line 7 times col 3, line 8)









14
15 Subtotal Allowance Amount (Sum of lines 12-14)









15
16 Aides (Col 4, line 7 times col 4, line 8)









16
17 Total Allowance Amount (Sum of lines 15 and 16)









17
If the sum of cols 1-3, line 7, is greater than line 2, make no entries on lines 18 and 19











and enter on line 20 the amount from line 17. Otherwise, complete lines 18-20.











18 Weighted average rate excluding aides (Line 15 divided by the sum of cols 1-3, line 7)









18
19 Weighted allowance excluding aides (Line 2 times line 18)









19
20 Total Salary Equivalency (Line 17 or sum of lines 16 plus 19)









20














PART III - TRAVEL ALLOWANCE AND TRAVEL EXPENSE COMPUTATION - HHA SERVICES











Standard Travel Allowance and Standard Travel Expense










21 Therapists (Line 3 times col 2, line 9)









21
22 Assistants (Line 4 times col 3, line 9)









22
23 Subtotal (Sum of lines 21 and 22)









23
24 Standard Travel Expense (Line 5 times sum of lines 3 and 4)









24

Optional Travel Allowance and Optional Travel Expense










25 Therapists (Sum of cols 1 and 2, line 10 times col 2, line 8)









25
26 Assistants (Col 3, line 10 times col 3, line 8)









26
27 Subtotal (Sum of lines 25 and 26)









27
28 Optional Travel Expense (Line 6 times sum of cols 1-3, line 11)









28

Total Travel Allowance and Travel Expenses - HHA Services; Complete one of the following











three lines 29, 30 or 31, as appropriate










29 Standard Travel Allowance and Standard Travel Expenses (Sum of lines 23 and 24 - See Instructions)









29
30 Optional Travel Allowance and Standard Travel Expenses (Sum of lines 27 and 24 - See Instructions)









30
31 Optional Travel Allowance and Optional Travel Expenses (Sum of lines 27 and 28 - See Instructions)









31

































































FORM CMS-1728-94-A-8-3 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC 3219-3219.3)
























32-316










Rev. 7

Sheet 17: A83-2

05-07



FORM CMS 1728-94




3290 (Cont.)
REASONABLE COST DETERMINATION FOR THERAPY




PROVIDER NO.:
PERIOD:
WORKSHEET A-8-3
SERVICES FURNISHED BY OUTSIDE SUPPLIERS






From: ___________
PART IV & V






________________
To: ___________


Check applicable box:

[ ] Physical Therapy services rendered before 4/10/98 [ ] Occupational Therapy [ ] Speech Pathology










[ ] Physical Therapy services rendered on or after 4/10/98




















PART IV - OVERTIME COMPUTATION
















Therapists Assistants Aides TOTAL


Description



1 2 3 4
32 Overtime hours worked during cost reporting period (If col 4, line 32, is zero or equal to or greater








32

than 2,080, do not complete lines 33-40 and enter zero in each column of line 41)









33 Overtime rate (Multiply the amounts in cols 2-4, line 8 (AHSEA) times 1.5)








33
34 Total overtime (Including base and overtime allowance) (Multiply line 32 times line 33)








34

CALCULATION OF LIMIT









35 Percentage of overtime hours by category (Divide the hours in each column on line 32 by the total








35

overtime worked - col. 4, line 32)









36 Allocation of provider's standard workyear for one full-time employee times the percentage on line 35)








36

(See Instructions)










DETERMINATION OF OVERTIME ALLOWANCE









37 Adjusted hourly salary equivalency amount (AHSEA) (From Part I, cols 2-4, line 8)








37
38 Overtime cost limitation (Line 36 times line 37)








38
39 Maximum overtime cost (Enter the lesser of line 34 or line 38)








39
40 Portion of overtime already included in hourly computation at the AHSEA (Multiply line 32 times line 37)








40
41 Overtime allowance (Line 39 minus line 40 - if negative enter zero) (Col 4, sum of cols 1-3)








41













PART V - COMPUTATION OF THERAPY LIMITATION AND EXCESS COST ADJUSTMENT









42 Salary equivalency amount (from Part II, line 20)








42
43 Travel allowance and expense - HHA services (from Part III, lines 29, 30 or 31)








43
44 Overtime allowance (from Part IV, col. 4, line 41)








44
45 Equipment cost (See Instructions)








45
46 Supplies (See Instructions)








46
47 Total allowance (Sum of lines 42-46)








47
48 Total cost of outside supplier services (from provider records)








48
49 Excess over limitation (line 48 minus line 47 - transfer amount to A-5, line 10, 10.1, or 10.2 as applicable - if negative, enter zero -- See Instructions)








49
































































































































































































































































































FORM CMS-1728-94-A-8-3 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECS 3219.4 AND 3219.5)






















Rev. 13









32-317

Sheet 18: B,B-1

3290 (Cont.)





FORM CMS 1728-94




05-07








PROVIDER NO.:
PERIOD:



COST ALLOCATION - GENERAL SERVICE COST







From: ___________
WORKSHEET B








_____________
To: ___________







NET EXPENSES CAPITAL










FOR COST RELATED COSTS PLANT









ALLOCATION

OPERATION

ADMINISTRA-






(FR.WKST BLDGS & MOVABLE & TRANS- SUBTOTAL TIVE






A, COL10) & FIXTURES EQUIPMENT MAINTENANCE PORTATION (cols. 0-4) & GENERAL TOTAL





0 1 2 3 4 4A 5 6

GENERAL SERVICE COST CENTERS











1 Capital Related - Bldg. and Fixtures



0





1
2 Capital Related - Movable Equipment



0 0




2
3 Plant Operation & Maintenance



0 0 0



3
4 Transportation (See Instructions)



0 0 0



4
5 Administrative and General










5

HHA REIMBURSABLE SERVICES











6 Skilled Nursing Care



0 0 0

0
6
7 Physical Therapy



0 0 0

0
7
8 Occupational Therapy



0 0 0

0
8
9 Speech Pathology



0 0 0

0
9
10 Medical Social Services



0 0 0

0
10
11 Home Health Aide



0 0 0

0
11
12 Supplies (See Instructions)



0 0 0

0
12
13 Drugs



0 0 0

0
13
13.20 Cost of Administering Vaccines










13.20
14 DME



0 0 0

0
14

HHA NONREIMBURSABLE SERVICES











15 Home Dialysis Aide Services










15
16 Respiratory Therapy










16
17 Private Duty Nursing










17
18 Clinic










18
19 Health Promotion Activities










19
20 Day Care Program










20
21 Home Delivered Meals Program










21
22 Homemaker Services










22
23 Other










23

SPECIAL PURPOSE COST CENTER











24 CORF










24
25 Hospice










25
26 CMHC










26
27 RHC










27
28 FQHC










28
29 Total



0 0 0

0
29
























































FORM CMS-1728-94-B (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC 3214)


























32-318











Rev. 13
05-07





FORM CMS 1728-94




3290 (Cont.)








PROVIDER NO.:
PERIOD:




COST ALLOCATION - STATISTICAL BASIS






From: ___________
WORKSHEET B-1







_____________
To: ___________








CAPITAL











RELATED COSTS PLANT

ADMINISTRA-







BLDGS & MOVABLE OPERATION

TIVE







& FIXTURES EQUIPMENT MAINTENANCE TRANS-
& GENERAL



COST CENTER


(SQUARE (DOLLAR (SQUARE PORTATION RECONCIL- (ACCUMU-







FEET) VALUE) FEET) (MILEAGE) IATION LATED COST) TOTAL






1 2 3 4 5A 5 6

GENERAL SERVICE COST CENTER











1 Capital Related - Bldg. and Fixtures










1
2 Capital Related - Movable Equipment










2
3 Plant Operation & Maintenance










3
4 Transportation (See Instructions)










4
5 Administrative and General










5

HHA REIMBURSABLE SERVICES











6 Skilled Nursing Care










6
7 Physical Therapy










7
8 Occupational Therapy










8
9 Speech Pathology










9
10 Medical Social Services










10
11 Home Health Aide










11
12 Supplies (See Instructions)










12
13 Drugs










13
13.20 Cost of Administering Vaccines










13.20
14 DME










14

HHA NONREIMBURSABLE SERVICES











15 Home Dialysis Aide Services










15
16 Respiratory Therapy










16
17 Private Duty Nursing










17
18 Clinic










18
19 Health Promotion Activities










19
20 Day Care Program










20
21 Home Delivered Meals Program










21
22 Homemaker Services










22
23 Other










23

SPECIAL PURPOSE COST CENTER











24 CORF










24
25 Hospice










25
26 CMHC










26
27 RHC










27
28 FQHC










28
29 Total










29
30 Cost To Be Allocated (Per Wkst B)










30
31 Unit Cost Multiplier









31
FORM CMS-1728-94-B-1 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC 3214)


























Rev. 13











32-319

Sheet 19: C

3290 (Cont.)







FORM CMS 1728-94





05-07
APPORTIONMENT OF PATIENT SERVICE COSTS








PROVIDER NO.:
PERIOD:

WORKSHEET C












From: ______________

PARTS I & II










______________
To: ______________



PART I - AGGREGATE AGENCY COST PER VISIT COMPUTATION






























Average
Cost Per Visit Computation










From Wkst

Cost












B, Col. 6, Total Per Visit

Patient Services









Line: Cost Visits (Cols 2 ÷ 3) (1)












1 2 3 4
1 Skilled Nursing









6


1
2 Physical Therapy









7


2
3 Occupational Therapy









8


3
4 Speech Pathology









9


4
5 Medical Social Services









10


5
6 Home Health Aide Services









11


6
7 Total (Sum of lines 1-6)













7

















PART II - COMPUTATION OF THE AGGREGATE MEDICARE COST AND THE AGGREGATE OF THE MEDICARE LIMITATION (2)
























Medicare Program Visits Cost of Medicare Services


MSA/CBSA CODE:







Part B
Part B








From Wkst. C, Average
Not Subject Subject
Not Subject Subject Total







Part I, Col. 4, Cost
to Deductibles to Deductibles
to Deductibles to Deductibles (Sum of

Total Medicare Patient Service Cost Computation




Line: Per Visit Part A & Coinsurance & Coinsurance Part A & Coinsurance & Coinsurance Cols 8 & 9)








4 5 6 7 8 9 10 11
1 Skilled Nursing




1







1
2 Physical Therapy




2







2
3 Occupational Therapy




3







3
4 Speech Pathology




4







4
5 Medical Social Services




5







5
6 Home Health Aide Services




6







6
7 Total (Sum of lines 1-6)













7


























Medicare Program Visits Cost of Medicare Services











Part B
Part B









Program
Not Subject Subject
Not Subject Subject Total








Cost
to Deductibles to Deductibles
to Deductibles to Deductibles (Sum of

Total Medicare Patient Service Cost Limitation Computation





Limits Part A & Coinsurance & Coinsurance Part A & Coinsurance & Coinsurance Cols 8 & 9








4 5 6 7 8 9 10 11
8 Skilled Nursing













8
9 Physical Therapy













9
10 Occupational Therapy













10
11 Speech Pathology













11
12 Medical Social Services













12
13 Home Health Aide Services













13
14 Total (Sum of lines 8-13 plus the subscripts of lines 1-6, respectively)













14

(1) Compute the average cost per visit one time for each discipline (column 4, lines 1 through 6) for the entire home health agency.















(2) Complete Worksheet C, Part II once for each MSA where Medicare covered services were furnished during the cost reporting period.











































































































































































































































FORM CMS-1728-94-C (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3215 - 3215.5)
































32-320














Rev. 13
05-07







FORM CMS 1728-94





3290 (Cont.)
APPORTIONMENT OF PATIENT SERVICE COSTS








PROVIDER NO.:
PERIOD:

WORKSHEET C












From: ______________

PARTS III, IV & V










______________
To: ______________



PART III - SUPPLIES AND DRUGS COST COMPUTATION

























Medicare Covered Charges Cost of Services








Total

Part B
Part B






From Wkst
Charges

Not Subject Subject
Not Subject Subject






B, Col. 6, Total from HHA Ratio
to Deductibles to Deductibles
to Deductibles to Deductibles

Other Patient Services



Line: Cost Record) (Col 2 ÷ 3) Part A & Coinsurance & Coinsurance Part A & Coinsurance & Coinsurance






1 2 3 4 5 6 7 8 9 10
15 Cost of Medical Supplies



12








15
16 Cost of Drugs



13








16
16.20 Cost of Drugs



13.20








16.20

















PART IV - COMPARISON OF THE LESSER OF THE AGGREGATE MEDICARE COST, THE AGGREGATE OF THE MEDICARE COST PER VISIT LIMITATION AND THE AGGREGATE PER BENEFICIARY COST LIMITATION

























Medicare Program Per Beneficiary














Unduplicated Annual Cost of Medicare Services











Census Count Limitation Per
Part B











For Each MSA MSA/Non-MSA
Not Subject Subject Total










Pre 10/1/2000 (From Your
to Deductibles to Deductibles (Sum of










(4) Intermediary) Part A & Coinsurance & Coinsurance Cols 3 & 4










1 2 3 4 5 6
17 Total Cost of Medicare Services (Sum of the amounts from each Wkst. C, Pt. II, cols. 8, 9 & 11, respectively, lines













17

1-6 (exculsive of subscripts))














18 Cost of Medical Supplies (from Part III, columns 8 and 9, line 15 (exclusive of line 15.01))













18
19 Total (Sum of lines 17 and 18)













19

















20 Total Cost Per Visit Limitation for Medicare Services (Sum of the amounts from each Wkst. C, Pt. II, cols. 8, 9 &11, respectively, line 14)













20
21 Cost of Medical Supplies (from Part III, columns 8 and 9, line 15 (exclusive of line 15.01))













21
22 Total (Sum of lines 20 and 21)













22


























MSA Code (3)




(Col 1 x 2)









0 1 2 3 4 5 6
23 Per Beneficiary Cost Limitation for MSA:













23
23.01 Per Beneficiary Cost Limitation for MSA:













23.01
23.02 Per Beneficiary Cost Limitation for MSA:













23.02
23.03 Per Beneficiary Cost Limitation for MSA:













23.03
23.04 Per Beneficiary Cost Limitation for MSA:













23.04
23.05 Per Beneficiary Cost Limitation for MSA:













23.05
23.06 Per Beneficiary Cost Limitation for MSA:













23.06
23.07 Per Beneficiary Cost Limitation for MSA:













23.07
23.08 Per Beneficiary Cost Limitation for MSA:













23.08
23.09 Per Beneficiary Cost Limitation for MSA:













23.09
24 Aggregate Per Beneficiary Cost Limitation (Sum of lines 23 and subscripts thereof)













24

















PART V - OUTPATIENT THERAPY REDUCTION COMPUTATION























Part B













Subject to Deductibles and Coinsurance













Medicare Medicare Medicare Medicare Medicare Medicare








From Wkst. C, Average Program Visits Program Costs Program Visits Program Visits Program Visits Program Costs Application of Reasonable






Part I, Col. 4, Cost for Services for Services for Services for Services for Services on for Services the Reasonable Costs Net of

Patient Services



Line: Per Visit Before 1/1/98 Before 1/1/98 1/1/98-12/31/98 1/1/99-9/30/00 or after 10/1/00 1/1/98-12/31/98 Cost Reduction Adjustments






1 2 3 4 5 5.01 5.02 6 7 8
25 Physical Therapy



2








25
26 Occupational Therapy



3








26
27 Speech Pathology



4








27
28 Total (Sum of lines 25-27)













28

(3) The MSA/CBSA codes flow from Worksheet S-3, Part III, line 29 and subscripts as indicated.















(4) The sum of column 1, line 24 must equal Worksheet S-3, Part I, column 2, line 10.01.














FORM CMS-1728-94-C (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3215 - 3215.5)


































































Rev. 13














32-321

Sheet 20: D

3290 (Cont.)
FORM CMS 1728-94



05-07
CALCULATION OF REIMBURSEMENT SETTLEMENT -

PROVIDER NO.:
PERIOD:

PART A AND PART B SERVICES



From: ___________ WORKSHEET D



________________
To: ___________

PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES










PART B




Not Subject Subject




to Deductibles to Deductibles



PART A & Coinsurance & Coinsurance

Description
1 2 3
Reasonable Cost of Title XVIII - Part A & Part B Services






1 Reasonable Cost of Services (See Instructions)




1
2 Cost of Services, RHC & FQHC




2
3 Sum of Lines 1 and 2




3
4 Total charges for title XVIII - Part A and Part B Services - Pre 10/1/2000




4
4.01 Total charges for title XVIII - Part A and Part B Services - Post 9/30/2000




4.01

Customary Charges





5 Amount actually collected from patients liable for payment for services on a




5

charge basis (From your records)





6 Amount that would have been realized from patients liable for payment for services on




6

a charge basis had such payment been made in accordance with 42 CFR 413.13(b)





7 Ratio of line 5 to 6 (Not to exceed 1.000000)




7
8 Total customary charges - title XVIII (Multiply line 7 by line 4 for column 1) (Multiply line 7




8

by the sum of lines 4 & 4.01 for columns 2 & 3, respectively) (See Instructions)





9 Excess of total customary charges over total reasonable cost (Complete only if




9

line 8 exceeds line 3)





10 Excess of reasonable cost over customary charges (Complete only if line 3 exceeds line 8)




10
11 Primary Payer Amounts




11








PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT










PART A PART B




Services Services

Description

1 2
12 Total reasonable cost (See Instructions)




12
12.01 Total PPS Payment - Full Episodes without Outliers




12.01
12.02 Total PPS Payment - Full Episodes with Outliers




12.02
12.03 Total PPS Payment - LUPA Episodes




12.03
12.04 Total PPS Payment - PEP Only Episodes




12.04
12.05 Total PPS Payment - SCIC within a PEP Episodes




12.05
12.06 Total PPS Payment - SCIC Only Episodes




12.06
12.07 Total PPS Outlier Payment - Full Episodes with Outliers




12.07
12.08 Total PPS Outlier Payment - PEP Only Episodes




12.08
12.09 Total PPS Outlier Payment - SCIC within a PEP Episodes




12.09
12.10 Total PPS Outlier Payment - SCIC Only Episodes




12.10
12.11 Total Other Payments




12.11
12.12 DME Payment




12.12
12.13 Oxygen Payment




12.13
12.14 Prosthetics and Orthotics Payment




12.14
13 Part B deductibles billed to Medicare patients (exclude coinsurance)




13
14 Subtotal (Sum of lines 12-12.14 minus line 13)




14
15 Excess reasonable cost (from line 10)




15
16 Subtotal (Line 14 minus line 15)




16
17 Coinsurance billed to Medicare patients (From your records)




17
18 Net cost (Line 16 minus line 17)




18
19 Reimbursable bad debts (From your records)




19
20 Pneumococcal Vaccine




20
21 Total Costs - Current cost reporting period (See Instructions)




21
22 Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets




22
23 Recovery of excess depreciation resulting from agencies' termination or decrease in Medicare utilization




23
24 Unrefunded charges to beneficiaries for excess costs erroneously collected based on correction of cost limit




24
25 Total cost before sequestration and other adjustments- (line 21




25

plus/minus line 22 minus sum of lines 23 and 24)





25.5 Other Adjustments (see instructions) (specify)




25.5
26 Sequestration Adjustment (See Instructions)




26
27 Amount reimbursable after sequestration and other adjustments (Line 25 plus line 25.5 minus line 26)




27
28 Total interim payments (From Worksheet D-1, line 4)




28
28.5 Tentative settlement (For intermediary use only)




28.5
29 Balance due HHA/Medicare program (Line 27 minus line 28) (Indicate overpayments in brackets)




29
30 Protested amounts (nonallowable cost report items) in accordance with CMS Pub. 15-II, section 115.2




30
31 Balance due HHA/Medicare program (Line 29 minus line 30) (Indicate overpayments in brackets)




31
FORM CMS-1728-94-D (3-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3216 - 3216.2)














32-322





Rev. 13

Sheet 21: D-1

08-99





FORM CMS 1728-94



3290 (Cont.)
ANALYSIS OF PAYMENTS TO HHAs




PROVIDER NO.:

PERIOD:
WORKSHEET D-1
FOR SERVICES RENDERED TO




_______________

From: ___________


PROGRAM BENEFICIARIES






To: ___________

















Description




PART A
PART B









mm/dd/yyyy Amount mm/dd/yyyy Amount








1 2 3 4
1 Total interim payments paid to provider









1
2 Interim pymts payable on individual bills either submitted or to









2

be submitted to the intermediary, for services rendered in the











cost reporting period. If none, write "NONE" or enter a zero.










3 List separately each retroactive lump sum




.01



3.01

adjustment amount based on subsequent revision




.02



3.02

of the interim rate for the cost reporting period.



Program .03



3.03

Also show date of each payment. If none write



to .04



3.04

"NONE" or enter a zero.(1)



Provider .05



3.05







.50



3.50






.51



3.51






Provider .52



3.52





to .53



3.53






Program .54



3.54

SUBTOTAL (Sum of lines 3.01-3.49, minus sum




.99





of lines 3.50-3.98)









3.99
4 TOTAL INTERIM PAYMENTS (Sum of lines 1, 2









4

and 3.99)(Transfer to Wkst D, Part II,











column as appropriate, line 28)



























TO BE COMPLETED BY INTERMEDIARY




















5 List separately each tentative settlement payment



Program .01



5.01

after desk review. Also show date of each



to .02



5.02

payment. If none, write "NONE" or enter



Provider .03



5.03

a zero. (1)



Provider .50



5.50

"NONE" or enter a zero. (1)



to .51



5.51






Program .52



5.52

SUBTOTAL (Sum of lines 5.01-5.49 minus sum




.99





of lines 5.50-5.98)









5.99
6 Determine net settlement



Program






amount (balance due) based



to .01





on the cost report (See



Provider




6.01

Instructions)



Provider











to .02










Program




6.02
7 TOTAL MEDICARE PROGRAM LIABILITY









7

(See Instructions)











Name of Intermediary






Intermediary Number





























Signature of Authorized Person






Date: Month, Day, Year




























(1) On lines 3, 5 and 6, where an amount is due "Provider to Program," show the amount and date on which the provider











agrees to the amount of repayment, even though total repayment is not accomplished until a later date.
























FORM CMS-1728-94-D-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3217)







































































































































































Rev. 7










32-323

Sheet 22: F

3290 (Cont.)




FORM CMS 1728-94



08-99

BALANCE SHEET



PROVIDER NO.:
PERIOD:


(To be completed by all providers maintaining fund type






From: ___________
WORKSHEET F
accounting records. Nonproprietary providers not




___________
To: ___________


maintaining fund type accounting records, should










complete the "General Fund" column only.)

















SPECIFIC






ASSETS

GENERAL PURPOSE
ENDOWMENT PLANT



(Omit Cents)

FUND FUND
FUND FUND






1
2 3 4



CURRENT ASSETS







1 Cash on hand and in banks








1
2 Temporary investments








2
3 Notes receivable








3
4 Accounts Receivable








4
5 Other Receivables








5
6 Less: Allowance for uncollectible notes








6

and accounts receivable



( )




7 Inventory








7
8 Prepaid Expenses








8
9 Other current assets








9
10 Due from other funds








10
11 TOTAL CURRENT ASSETS (Sum of lines 1-10)








11



FIXED ASSETS







12 Land








12
13 Land Improvements








13
14 Less: Accumulated Depreciation



( )



14
15 Buildings








15
16 Less: Accumulated Depreciation



( )



16
17 Leasehold improvements








17
18 Less: Accumulated Depreciation



( )



18
19 Fixed equipment








19
20 Less: Accumulated Depreciation



( )



20
21 Automobiles and trucks








21
22 Less: Accumulated Depreciation



( )



22
23 Major movable equipment








23
24 Less: Accumulated Depreciation



( )



24
25 Minor equipment nondepreciable








25
26 Other fixed assets








26
27 TOTAL FIXED ASSETS (Sum of lines 12-26)








27



OTHER ASSETS







28 Investments








28
29 Deposits on leases








29
30 Due from owners/officers








30
31









31
32 TOTAL OTHER ASSETS (Sum of lines 28-31)








32
33 TOTAL ASSETS (Sum of lines 11, 27 and 32)








33


LIABILITIES AND FUND BALANCE











(Omit Cents)










CURRENT LIABILITIES







34 Accounts payable








34
35 Salaries, wages & fees payable








35
36 Payroll taxes payable








36
37 Notes & loans payable (short term)








37
38 Deferred income








38
39 Accelerated payments








39
40 Due to other funds








40
41 Other (Specify)








41
42 TOTAL CURRENT LIABILITIES (Sum of lines 34-41)








42


LONG TERM LIABILITIES








43 Mortgage payable








43
44 Notes payable








44
45 Unsecured Loans








45
46 Loans from owners - prior to 7/1/66








46
47 Loans from owners - on or after 7/1/66








47
48 Other (Specify)








48
49 TOTAL LONG TERM LIABILITIES








49

(Sum of lines 43-48)









50 TOTAL LIABILITIES (Sum of lines 42 and 49)








50


CAPITAL ACCOUNTS








51 General fund balance








51
52 Specific purpose fund balance








52
53 Donor created--Endowment fund balance--restricted








53
54 Donor created--Endowment fund balance--unrestricted








54
55 Governing body created--Endowment fund balance








55
56 Plant fund balance--Invested in plant








56
57 Plant fund balance-- Reserve for plant improvement,








57

replacement and expansion









58 TOTAL FUND BALANCES (Sum of lines 51 thru 57)








58
59 TOTAL LIABILITIES AND FUND BALANCE (Sum








59

of lines 50 and 58)














( ) = contra amount





FORM CMS-1728-94-F (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3218)






















32-324









Rev. 7

Sheet 23: F-1

08-99


FORM CMS 1728-94


3290 (Cont.)
STATEMENT OF


PROVIDER NO.:
PERIOD

REVENUE AND EXPENSES




From: ___________ WORKSHEET F-1




___________
To: ___________

1 Total patient revenues





1









2 Less: Allowances and discounts on patients' accounts





2









3 Net patient revenues (Line 1 minus line 2)





3









4 Operating expenses (From Worksheet A, column 6, line 29)





4









5 Additions to operating expenses (Specify)





5









6






6









7






7









8






8









9






9









10






10









11 Subtractions from operating expenses (Specify)





11









12






12









13






13









14






14









15






15









16






16









17 Less total operating expenses (net of lines 4 thru 16)





17









18 Net income from service to patients (Line 3 minus line 17)





18










Other income:















19 Contributions, donations, bequests, etc.





19









20 Income from investments





20









21 Purchase discounts





21









22 Rebates and refunds of expenses





22









23 Sale of Medical and Nursing Supplies to other than patients





23









24 Sale of durable medical equipment to other than patients





24









25 Sale of drugs to other than patients





25









26 Sale of medical records and abstracts





26









27 Other revenues (Specify)





27









28






28









29






29









30






30









31






31









32 Total Other Income (Sum of lines 19 thru 31)





32









33 Net Income or Loss for the period (Line 18 plus line 32)





33









FORM CMS-1728-94 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II SEC. 3218)
















Rev. 7






32-325

Sheet 24: F-2

3290 (Cont.)






FORM CMS 1728-94




08-99









PROVIDER NO.:
PERIOD:


STATEMENT OF CHANGES IN FUND BALANCES









From: ___________
WORKSHEET F-2









___________
To: ___________








GENERAL FUND SPECIFIC PURPOSE FUND ENDOWMENT FUND PLANT FUND






1 2 3 4 5 6 7 8















1 Fund balances at beginning of period











1















2 Net Income (loss) (From Worksheet F-1, line 33)











2















3 Total (Sum of line 1 and line 2)











3















4 Additions (Credit adjustments) (Specify)











4















5












5















6












6















7












7















8












8















9 Total Additions (Sum of lines 4-8)











9















10 Subtotal (line 3 plus line 9)











10















11 Deductions (Debit adjustments) (Specify)











11















12












12















13












13















14












14















15












15















16 Total Deductions (Sum of lines 11-15)











16

Fund balance at end of period per balance sheet












17 (line 10 minus line 16)











17
























































































































FORM CMS-1728-94-F-2 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3218)




























32-326












Rev. 7

Sheet 25: J-1 & J-2

08-99






FORM CMS 1728-94





3290 (Cont.)








PROVIDER NO.:

PERIOD:

WORKSHEET J-1
ALLOCATION OF GENERAL SERVICE






___________________

FROM: _______________

PARTS I & II
COSTS TO CORF REIMBURSABLE COST CENTERS






CORF NO.:

TO: _________________











___________________






PART I - ALLOCATION OF GENERAL SERVICE COSTS TO CORF REIMBURSABLE COST CENTERS



















NET CAPITAL PLANT



ALLOCATED






EXPENSES RELATED COSTS OPERATION

A&G
CORF TOTAL

CORF COST CENTER FOR COST BLDGS & MOVABLE & MAINTE- TRANSPOR- SUBTOTAL SHARED SUB- A&G (SEE (SUM OF

(OMIT CENTS) ALLOCATION (1) FIXTURES EQUIPMENT NANCE TATION (cols. 0-4) COSTS TOTAL PART II) COLS 6 & 7)





0 1 2 3 4 4A 5 6 7 8
1 Administrative and General












1
2 Skilled Nursing Care












2
3 Physical Therapy












3
4 Occupational Therapy












4
5 Speech Pathology












5
6 Medical Social Services












6
7 Respiratory Therapy












7
8 Psychological Services












8
9 Prosthetic and Orthotic Devices












9
10 Drugs and Biologicals












10
11 Medical Supplies












11
12 Durable Medical Equipment-Rented












12
13 Durable Medical Equipment-Sold












13
14 Other Part B Services












14
15 TOTALS (Sum of lines 1-14) (2)












15

(1) Column 0, line 15 must agree with Wkst. A, column 10, line 24.














(2) Columns 0 through 5, line 15 must agree with the corresponding columns of Wkst. B, line 24



































0 0 0 0 0




PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF CORF ADMINISTRATIVE AND GENERAL COSTS














1 Amount from Part I, column 6, line 15












1
2 Amount from Part I, column 6, line 1












2
3 Line 1 minus line 2












3
4 Unit cost multiplier for CORF A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,












4

lines 2 through 14, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)





























































































































































































































































































FORM CMS 1728-94-J-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3221-3221.2)






























Rev. 7













32-327
05-00






FORM CMS 1728-94





3290 (Cont.)








PROVIDER NO.:

PERIOD:

WORKSHEET J-2
COMPUTATION OF CORF COSTS






___________________

FROM: _______________











CORF NO.:

TO: __________________











___________________






PART I - APPORTIONMENT OF CORF COST CENTERS NET OF THE APPLICABLE REASONABLE COST REDUCTION

























TITLE XVIII

TITLE XVIII






TOTAL COSTS
RATIO OF
TITLE XVIII CORF TITLE XVIII REASONABLE COST NET OF






(FROM SUPP. TOTAL COSTS TO TITLE XVIII CORF COSTS CHARGES ON CORF COST REASONABLE

CORF COST CENTER


WKST. J-1, PT. CORF CHARGES CORF (COL. 3 X OR AFTER COSTS ON OR REDUCTION COST

(OMIT CENTS)


I, COL. 8) (1) CHARGES (2) (COL. 1 / COL. 2) CHARGES * COL. 4) 1/1/98 * AFTER 1/1/98 AMOUNT REDUCTION






1 2 3 4 5 6 7 8 9
1 Administrative and General












1
2 Skilled Nursing Care












2
3 Physical Therapy












3
4 Occupational Therapy












4
5 Speech Pathology












5
6 Medical Social Services












6
7 Respiratory Therapy












7
8 Psychological Services












8
9 Prosthetic and Orthotic Devices












9
10 Drugs and Biologicals












10
11 Medical Supplies












11
12 Durable Medical Equipment-Rented












12
13 Durable Medical Equipment-Sold












13
14 Other Part B Services












14
15 TOTALS (Sum of lines 2-14)












15
















PART II - APPORTIONMENT OF COST OF CORF














SERVICES FURNISHED BY HHA DEPARTMENTS



Fr. Wkst. B,














Col 6, Line:









16 Respiratory Therapy


16








16
17 Physical Therapy


7








17
18 Occupational Therapy


8








18
19 Speech Pathology


9








19
20 Supplies


12








20
21 Drugs Charged to Patients


13








21
















23 Total (Sum of lines 16 through 21)












23

(1) Cost for Part II, lines 16-22 are obtained from Worksheet B, column 6, lines as appropriate














(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records





























PART III- TOTAL CORF COSTS







4 5 6 7 8 9
24 Total CORF costs - Add the amount from Part I, column 9, line 15 and the amount from Part II, column 9, line 23.












24

Add the amounts from Part I, line 15 and Part II, line 23 for columns 4 through 8, respectively.













Transfer the amount in Part III, column 9 to Worksheet J-3, line 1.






























* See instructions for fee scheduled payment basis items for services rendered on or after January 1, 1999.






























































































FORM CMS 1728-94-J-A932 (8-1999) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3222-3222.3)






























Rev. 9













32-329

Sheet 26: J-1, PT3

3290 (Cont.)





FORM CMS 1728-94






08-99
ALLOCATION OF GENERAL SERVICE






PROVIDER NO.:

PERIOD:
WORKSHEET J-1

COSTS TO CORF COST CENTERS






___________________

FROM: _____________
PART III









CORF NO.:

TO: ________________











___________________






PART III - ALLOCATION OF GENERAL SERVICE COSTS TO CORF COST CENTERS - STATISTICAL BASIS

















CAPITAL











RELATED COSTS PLANT













OPERATION









BLDGS & MOVABLE & MAINTE-



ADMINISTRATIVE



FIXTURES EQUIPMENT NANCE TRANSPOR-

& GENERAL

CORF COST CENTER (SQUARE (SQUARE (SQUARE TATION RECONCIL- (ACCUMULATED

(OMIT CENTS) FEET) FEET) FEET) (MILEAGE) IATION COST)



1 2 3 4 5A 5
1 Administrative and General












1
2 Skilled Nursing Care












2
3 Physical Therapy












3
4 Occupational Therapy












4
5 Speech Pathology












5
6 Medical Social Services












6
7 Respiratory Therapy












7
8 Psychological Services












8
9 Prosthetic and Orthotic Devices












9
10 Drugs and Biologicals












10
11 Medical Supplies












11
12 Durable Medical Equipment-Rented












12
13 Durable Medical Equipment-Sold












13
14 Other Part B Services












14
15 TOTALS (Sum of lines 1-14)












15
16 Total Cost to be Allocated












16
17 Unit Cost Multiplier












17
















































































































































































































































































































































































FORM CMS 1728-94-J-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SEC. 3221.3)






























32-328













Rev. 7

Sheet 27: J-3

3290 (Cont.)


FORM CMS 1728-94


05-00



CORF NO.: FROM: _______________

WORKSHEET J-3
CALCULATION OF REIMBURSEMENT

___________________ TO: _________________



SETTLEMENT - CORF SERVICES


































PART I-COMPUTATION OF CUSTOMARY CHARGES FOR CORF SERVICES

























1 Total reasonable cost of CORF services (See instructions)





1
1.1 Total reasonable cost of CORF services prior to 1/1/1998 (Reasonable cost basis) (See instructions)





1.1
1.2 Total reasonable cost of CORF services on or after 1/1/1998 (Subject to LCC) (See instructions)





1.2
2 Primary payment amounts (CORF services)





2
3 Net cost (Line 1 minus line 2)





3
4 Total CORF charges





4

Customary Charges






5 Amounts actually collected from patients liable





5

for payments for CORF services on a charge basis (From







your records)






6 Amount that would have been realized from patients





6

liable for payment for CORF services on a charge basis







had such payment been made in accordance with







42 CFR 413.13(b)






7 Ratio of line 5 to line 6 (Not to exceed 1.000000)





7
8 Total customary charges - CORF services (Multiply line 7 x line 4)





8
8.1 Total customary charges - CORF services prior to 1/1/1998 (Reasonable cost basis) (See instructions)





8.1
8.2 Total customary charges - CORF services on or after 1/1/1998 (Subject to LCC) (See instructions)





8.2










COMPUTATION OF LESSER OF REASONABLE COSTS OR CUSTOMARY CHARGES FOR CORF







SERVICES FURNISHED IN CALENDAR YEAR 1998






8.3 Excess of customary charges over reasonable costs (Complete only if line 8.2 exceeds line 1.2) (See instructions)





8.3
8.4 Excess of reasonable costs over customary charges (Complete only if line 1.2 exceeds line 8.2) (See instructions)





8.4



























PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT
















9 Cost of CORF services (From line 3 )





9
10 Part B deductible billed to Program patients (exclude coinsurance amounts)





10
11 Net Cost (Line 9 minus line 10)





11
11.1 Excess of reasonable costs over customary charges for services rendered on or after 1/1/1998 (from line 8.4)





11.1
11.2 Subtotal (line11 minus line 11.1)





11.2
12 80% of Part B cost (80% x line 11.2)





12
13 Actual coinsurance billed to Program patients (From your records)





13
14 Net cost less actual billed coinsurance (Line 11 minus line 13)





14
15 Reimbursable bad debts (See instructions)





15
16 Net reimbursable amount (Line 15 plus the lesser of line 12 or line 14)





16
17 Amounts applicable to prior cost reporting periods resulting from disposition





17

of depreciable assets






18 Recovery of excess depreciation resulting from facility's termination or a decrease in





18

Program utilization






19 Other adjustments (specify)





19
20 Total Cost - reimbursable to provider (Line 16 minus lines 17 and 18 and plus or minus line 19)





20
21 Sequestration Adjustment (See instructions)





21
22 Amount due provider after sequestration adjustment (Amount on line 20 minus line 21)





22
23 Interim payments





23
23.5 Tentative settlement (For intermediary use only)





23.5
24 Balance due CORF/Program (Line 22 minus line 23) (Indicate overpayments in brackets)





24
25 Protested amounts (nonallowable cost report items) in accordance with PRM II, Sec. 115.2(B)





25
26 Balance due CORF/Program (Line 24 minus line 25) (Indicate overpayments in brackets)





26
FORM CMS 1728-94-J-3 (5-2000) (INSTRUCTIONS PUBLISHED IN THIS WORKSHEET ARE PUBLISHED IN CMS







PUB. 15-II, SEC. 3223-3223.2
















32-330




Rev. 9

Sheet 28: J-4

05-07

FORM CMS 1728-94



3290 (Cont.)
ANALYSIS OF PAYMENTS TO

CORF NO.: FROM: _______________

WORKSHEET J-4
PROVIDER-BASED CORF FOR

___________________ TO: _________________



SERVICES RENDERED TO PROGRAM







BENEFICIARIES

















DESCRIPTION

PART B






1 2






mm/dd/yyyy Amount
1 Total interim payments paid to CORF





1
2 Interim payments payable on individual bills either, submitted or to





2

be submitted to the intermediary, for services rendered in the







cost reporting period. If none, write "NONE" or enter a zero.






3 List separately each retroactive lump sum


.01

3.01

adjustment amount based on subsequent revision

Program .02

3.02

of the interim rate for the cost reporting period.

to .03

3.03

Also show date of each payment. If none write

Provider .04

3.04

"NONE" or enter a zero. (1)


.05

3.05





.50

3.50




Provider .51

3.51




to .52

3.52




Program .53

3.53





.54

3.54

SUBTOTAL (Sum of lines 3.01-3.49, minus sum







of lines 3.50-3.98)


.99

3.99
4 TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)





4

(Transfer to Supp. Wkst J-3, Part II, line 23)

















TO BE COMPLETED BY INTERMEDIARY









5 List separately each tentative settlement payment

Program .01

5.01

after desk review. Also show date of each

to .02

5.02

payment. If none, write "NONE" or enter

Provider .03

5.03

a zero. (1)

Provider .50

5.50




to .51

5.51




Program .52

5.52

SUBTOTAL (Sum of lines 5.01-5.49, minus sum







of lines 5.50-5.98)


.99

5.99
6 Determine net settlement amount (balance due) based

Program




on the cost report (SEE INSTRUCTIONS). (1)

to







Provider .01

6.01




Provider







to







Program .02

6.02
7 TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)





7









Name of Intermediary



Intermediary Number




















Signature of Authorized Person



Date: (Month, Day, Year)




















(1) On lines 3, 5 and 6, where an amount is due "Provider to Program," show the amount and date on which the provider







agrees to the amount of repayment, even though total repayment is not accomplished until a later date.




















































FORM CMS-1728-94-J-4 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II,







SEC. 3224
















Rev. 13






32-331

Sheet 29: K

3290 (Cont.)



FORM CMS 1728-94





05-07
RECLASSIFICATION AND ADJUSTMENT OF TRIAL BALANCE OF EXPENSES





PROVIDER NO:
PERIOD:
WORKSHEET K







_
FROM: ____________









HOSPICE NO.:
TO: _______________









_









CON-









EMPLOYEE
TRACTED








SALARIES BENEFITS TRANSPOR- SERVICES


SUBTOTAL
TOTAL

COST CENTER DESCRIPTIONS (From (From TATION (From
TOTAL RECLAS- (col. 6 ADJUST- (col. 8


Wkst.K-1) Wkst. K-2) (See inst.) Wkst. K-3) OTHER (cols. 1-5) SIFICATION ± col. 7) MENTS ± col. 9)


1 2 3 4 5 6 7 8 9 10

GENERAL SERVICE COST CENTERS






1 Capital Related Costs-Bldg and Fixt.






1
2 Capital Related Costs-Movable Equip.






2
3 Plant Operation and Maintenance









3
4 Transportation - Staff









4
5 Volunteer Service Coordination









5
6 Administrative and General









6

INPATIENT CARE SERVICE










7 Inpatient - General Care









7
8 Inpatient - Respite Care









8

VISITING SERVICES










9 Physician Services









9
10 Nursing Care









10
10.20 Nursing Care - Continuous Home Care









10.20
11 Physical Therapy









11
12 Occupational Therapy









12
13 Speech/ Language Pathology









13
14 Medical Social Services









14
15 Spiritual Counseling





15
16 Dietary Counseling









16
17 Counseling - Other









17
18 Home Health Aide and Homemaker









18
18.20 Home Health Aide and Homemaker-Cont Home Care









18.20
19 Other









19

OTHER HOSPICE SERVICE COSTS










20 Drugs, Biological and Infusion Therapy









20
20.30 Analgesics









20.30
20.31 Sedatives/Hypnotics









20.31
20.32 Other - specify









20.32
21 Durable Medical Equipment/Oxygen









21
22 Patient Transportation









22
23 Imaging Services









23
24 Labs and Diagnostics









24
25 Medical Supplies









25
26 Outpatient Services (incl. E/R Dept.)









26
27 Radiation Therapy









27
28 Chemotherapy









28
29 Other









29

HOSPICE NONREIMBURSABLE SERV.










30 Bereavement Program Costs









30
31 Volunteer Program Costs









31
32 Fundraising









32
33 Other Program Costs









33
34 Total (sum of line 1 thru 33)









34

The net expenses for cost allocation on Worksheet A for the Hospice cost center line must equal the total facility costs in column 10, line 34 of this worksheet.























FORM CMS-1728-94-K (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3240)
























32-331.1










Rev. 13

Sheet 30: K-1

05-07



FORM CMS 1728-94




3290 (Cont.)
COMPENSATION ANALYSIS - SALARIES AND WAGES




PROVIDER NO:
PERIOD:
WORKSHEET K-1






_
FROM: ____________








HOSPICE NO.:
TO: _______________








_

















COST CENTER DESCRIPTIONS ADMINIS
SOCIAL SUPER-
TOTAL




(omit cents) TRATOR DIRECTOR SERVICES VISORS NURSES THERAPISTS AIDES ALL OTHER TOTAL (1)


1 2 3 4 5 6 7 8 9

GENERAL SERVICE COST CENTERS





1 Capital Related Costs-Bldg and Fixt.






1
2 Capital Related Costs-Movable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6

INPATIENT CARE SERVICE









7 Inpatient - General Care








7
8 Inpatient - Respite Care








8

VISITING SERVICES









9 Physician Services








9
10 Nursing Care








10
10.20 Nursing Care - Continuous Home Care








10.20
11 Physical Therapy








11
12 Occupational Therapy








12
13 Speech/ Language Pathology








13
14 Medical Social Services








14
15 Spiritual Counseling




15
16 Dietary Counseling








16
17 Counseling - Other








17
18 Home Health Aide and Homemaker








18
18.20 Home Health Aide and Homemaker-Cont Home Care








18.20
19 Other








19

OTHER HOSPICE SERVICE COSTS









20 Drugs Biological and Infusion Therapy








20
20.30 Analgesics








20.30
20.31 Sedatives/Hypnotics








20.31
20.32 Other - specify








20.32
21 Durable Medical Equipment/ Oxygen








21
22 Patient Transportation








22
23 Imaging Services








23
24 Labs and Diagnostics








24
25 Medical Supplies








25
26 Outpatient Services (incl. E/R Dept.)








26
27 Radiation Therapy








27
28 Chemotherapy








28
29 Other








29

HOSPICE NONREIMBURSABLE SERV.









30 Bereavement Program Costs








30
31 Volunteer Program Costs








31
32 Fundraising








32
33 Other Program Costs








33
34 Total (sum of line 1 thru 33)








34
(1) Transfer the amount in column 9 to Wkst K, column 1










FORM CMS-1728-94-K-1 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3241)






















Rev. 13









32-331.2

Sheet 31: K-2

3290 (Cont.)



FORM CMS 1728-94




05-07
COMPENSATION ANALYSIS - EMPLOYEE BENEFITS (PAYROLL RELATED)




PROVIDER NO:
PERIOD:
WORKSHEET K-2






_
FROM: ____________








HOSPICE NO.:
TO: _______________








_

















COST CENTER DESCRIPTIONS ADMINIS
SOCIAL SUPER-
TOTAL




(omit cents) TRATOR DIRECTOR SERVICES VISORS NURSES THERAPISTS AIDES ALL OTHER TOTAL (1)


1 2 3 4 5 6 7 8 9

GENERAL SERVICE COST CENTERS





1 Capital Related Costs-Bldg and Fixt.






1
2 Capital Related Costs-Movable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6

INPATIENT CARE SERVICE









7 Inpatient - General Care








7
8 Inpatient - Respite Care








8

VISITING SERVICES









9 Physician Services








9
10 Nursing Care








10
10.20 Nursing Care - Continuous Home Care








10.20
11 Physical Therapy








11
12 Occupational Therapy








12
13 Speech/ Language Pathology








13
14 Medical Social Services








14
15 Spiritual Counseling




15
16 Dietary Counseling








16
17 Counseling - Other








17
18 Home Health Aide and Homemaker








18
18.20 Home Health Aide and Homemaker-Cont Home Care








18.20
19 Other








19

OTHER HOSPICE SERVICE COSTS









20 Drugs Biological and Infusion Therapy








20
20.30 Analgesics








20.30
20.31 Sedatives/Hypnotics








20.31
20.32 Other - specify








20.32
21 Durable Medical Equipment/ Oxygen








21
22 Patient Transportation








22
23 Imaging Services








23
24 Labs and Diagnostics








24
25 Medical Supplies








25
26 Outpatient Services (incl. E/R Dept.)








26
27 Radiation Therapy








27
28 Chemotherapy








28
29 Other








29

HOSPICE NONREIMBURSABLE SERV.









30 Bereavement Program Costs








30
31 Volunteer Program Costs








31
32 Fundraising








32
33 Other Program Costs








33
34 Total (sum of line 1 thru 33)








34
(1) Transfer the amount in column 9 to Wkst K, column 2










FORM CMS-1728-94-K-2 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3242)






















32-331.3









Rev. 13

Sheet 32: K-3

05-07



FORM CMS 1728-94




3290 (Cont.)
COMPENSATION ANALYSIS - CONTRACTED SERVICES/PURCHASED SERVICES




PROVIDER NO:
PERIOD:
WORKSHEET K-3






_
FROM: ____________








HOSPICE NO.:
TO: _______________








_

















COST CENTER DESCRIPTIONS ADMINIS
SOCIAL SUPER-
TOTAL




(omit cents) TRATOR DIRECTOR SERVICES VISORS NURSES THERAPISTS AIDES ALL OTHER TOTAL (1)


1 2 3 4 5 6 7 8 9

GENERAL SERVICE COST CENTERS





1 Capital Related Costs-Bldg and Fixt.






1
2 Capital Related Costs-Movable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6

INPATIENT CARE SERVICE









7 Inpatient - General Care








7
8 Inpatient - Respite Care








8

VISITING SERVICES









9 Physician Services








9
10 Nursing Care








10
10.20 Nursing Care - Continuous Home Care








10.20
11 Physical Therapy








11
12 Occupational Therapy








12
13 Speech/ Language Pathology








13
14 Medical Social Services








14
15 Spiritual Counseling




15
16 Dietary Counseling








16
17 Counseling - Other








17
18 Home Health Aide and Homemaker








18
18.20 Home Health Aide and Homemaker-Cont Home Care








18.20
19 Other








19

OTHER HOSPICE SERVICE COSTS









20 Drugs, Biological and Infusion Therapy








20
20.30 Analgesics








20.30
20.31 Sedatives/Hypnotics








20.31
20.32 Other - specify








20.32
21 Durable Medical Equipment/Oxygen







21
22 Patient Transportation








22
23 Imaging Services








23
24 Labs and Diagnostics








24
25 Medical Supplies








25
26 Outpatient Services (incl. E/R Dept.)








26
27 Radiation Therapy








27
28 Chemotherapy








28
29 Other








29

HOSPICE NONREIMBURSABLE SERV.









30 Bereavement Program Costs








30
31 Volunteer Program Costs








31
32 Fundraising








32
33 Other Program Costs








33
34 Total (sum of line 1 thru 33)








34
(1) Transfer the amount in column 9 to Wkst K, column 4










FORM CMS-1728-94-K-3 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3243)






















Rev. 13









32-331.4

Sheet 33: K-4I

3290 (Cont.)



FORM CMS 1728-94




05-07
COST ALLOCATION - HOSPICE GENERAL SERVICE COST




PROVIDER NO:
PERIOD:
WORKSHEET K-4






_
FROM: ____________
PART I






HOSPICE NO.:
TO: _______________








_






NET










EXPENSES










FOR COST CAPITAL RELATED

VOLUNTEER




COST CENTER DESCRIPTIONS ALLOC. COST PLANT
SERVICES
ADMINIS-



(FR. WKST K, BUILDINGS MOVABLE OPERATION TRANS- COORDI- SUBTOTAL TRATIVE &



COL. 10) & FIXTURES EQUIPMENT & MAINT. PORTATION NATOR (col. 0 - 5) GENERAL TOTAL


0 1 2 3 4 5 5A 6 7

GENERAL SERVICE COST CENTERS







1 Capital Related Costs-Bldg and Fixt.






1
2 Capital Related Costs-Movable Equip.






2
3 Plant Operation and Maintenance








3
4 Transportation - Staff








4
5 Volunteer Service Coordination








5
6 Administrative and General








6

INPATIENT CARE SERVICE









7 Inpatient - General Care








7
8 Inpatient - Respite Care








8

VISITING SERVICES









9 Physician Services








9
10 Nursing Care








10
10.20 Nursing Care - Continuous Home Care








10.20
11 Physical Therapy








11
12 Occupational Therapy








12
13 Speech/ Language Pathology








13
14 Medical Social Services - Direct








14
15 Spiritual Counseling






15
16 Dietary Counseling








16
17 Counseling - Other








17
18 Home Health Aide and Homemakers








18
18.20 Home Health Aide and Homemaker-Cont Home Care








18.20
19 Other








19

OTHER HOSPICE SERVICE COSTS









20 Drugs, Biologicals and Infusion








20
20.30 Analgesics








20.30
20.31 Sedatives/Hypnotics








20.31
20.32 Other - specify








20.32
21 Durable Medical Equipment/Oxygen








21
22 Patient Transportation








22
23 Imaging Services








23
24 Labs and Diagnostics








24
25 Medical Supplies








25
26 Outpatient Services (incl. E/R Dept.)








26
27 Radiation Therapy








27
28 Chemotherapy








28
29 Other








29

HOSPICE NONREIMBURSABLE SERV.









30 Bereavement Program Costs








30
31 Volunteer Program Costs








31
32 Fundraising








32
33 Other Program Costs








33
34 Total (sum of line 1 thru 33)








34
FORM CMS-1728-94-K-4 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3244)






















32-331.5









Rev. 13

Sheet 34: K-4II

05-07


FORM CMS-1728-94



3290 (Cont.)
COST ALLOCATION - HOSPICE STATISTICAL BASIS


PROVIDER NO:
PERIOD:
WORKSHEET K-4




_
FROM: ____________
PART II




HOSPICE NO.:
TO: _______________






_






CAPITAL RELATED







COST

VOLUNTEER




BUILDINGS MOVABLE PLANT
SERVICES
ADMINIS-


& FIXTURES EQUIPMENT OPERATION TRANS- COORDI-
TRATIVE &

COST CENTER DESCRIPTIONS (SQUARE (DOLLAR & MAINT. PORTATION NATOR RECON- GENERAL


FEET) VALUE) (SQ. FT.) (MILEAGE) (HOURS) CILIATION (ACC. COST)


1 2 3 4 5 6A 6

GENERAL SERVICE COST CENTERS





1 Capital Related Costs-Buildings and Fixtures




1
2 Capital Related Costs-Movable Equipment




2
3 Plant Operation and Maintenance






3
4 Transportation-staff






4
5 Volunteer Service Coordination






5
6 Administrative and General






6

INPATIENT CARE SERVICE







7 Inpatient - General Care






7
8 Inpatient - Respite Care






8

VISITING SERVICES







9 Physician Services






9
10 Nursing Care






10
10.20 Nursing Care - Continuous Home Care






10.20
11 Physical Therapy






11
12 Occupational Therapy






12
13 Speech/ Language Pathology






13
14 Medical Social Services - Direct






14
15 Spiritual Counseling




15
16 Dietary Counseling






16
17 Counseling - Other






17
18 Home Health Aide and Homemakers






18
18.20 Home Health Aide and Homemaker-Cont Home Care






18.20
19 Other






19

OTHER HOSPICE SERVICE COSTS







20 Drugs, Biologicals and Infusion






20
20.30 Analgesics






20.30
20.31 Sedatives/Hypnotics






20.31
20.32 Other - specify






20.32
21 Durable Medical Equipment/Oxygen






21
22 Patient Transportation






22
23 Imaging Services






23
34 Labs and Diagnostics






24
25 Medical Supplies






25
26 Outpatient Services (incl. E/R Dept.)






26
27 Radiation Therapy






27
28 Chemotherapy






28
29 Other






29

HOSPICE NONREIMBURSABLE SERV.







30 Bereavement Program Costs






30
31 Volunteer Program Costs






31
32 Fundraising






32
33 Other Program Costs






33
34 Cost To be Allocated (per Wkst K-4, Part I)






34
35 Unit Cost Multiplier






35










FORM CMS-1728-94-K-4 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3244)


















Rev. 13







32-331.6

Sheet 35: K-5I

3290 (Cont.)




FORM CMS 1728-94






05-07
ALLOCATION OF GENERAL SERVICE







PROVIDER NO:
PERIOD:
WORKSHEET K-5
COSTS TO HOSPICE COST CENTERS







_
FROM: ____________
PART I









HOSPICE NO.:
TO: _______________











_






















From HOSPICE CAPITAL RELATED PLANT



ALLOCATED TOTAL

HOSPICE COST CENTER
Wkst. K-4 TRIAL COST OPERATION

ADMINIS-
HOSPICE HOSPICE

(omit cents)
Part I, BALANCE BUILDINGS MOVABLE & MAIN- TRANS- SUBTOTAL TRATIVE & SUB- A&G (see COSTS



col. 7, (1) & FIXTURES EQUIPMENT TENANCE PORTATION (cols. 0-4) GENERAL TOTAL Part II) (col 6 + col. 7)



line 0 1 2 3 4 4A 5 6 7 8
1 Administrative and General
6









1
2 Inpatient - General Care
7









2
3 Inpatient - Respite Care
8









3
4 Physician Services
9









4
5 Nursing Care
10









5
5.20 Nursing Care - Continuous Home Care
10.20









5.20
6 Physical Therapy
11









6
7 Occupational Therapy
12









7
8 Speech/ Language Pathology
13









8
9 Medical Social Services - Direct
14









9
10 Spiritual Counseling
15









10
11 Dietary Counseling
16









11
12 Counseling - Other
17









12
13 Home Health Aide and Homemakers
18









13
13.20 Home Health Aide and
18.20









13.20

Homemaker-Cont Home Care












14 Other
19









14
15 Drugs, Biologicals and Infusion
20









15
15.30 Analgesics
20.30









15.30
15.31 Sedatives/Hypnotics
20.31









15.31
15.32 Other - specify
20.32









15.32
16 Durable Medical Equipment/Oxygen
21









16
17 Patient Transportation
22









17
18 Imaging Services
23









18
19 Labs and Diagnostics
24









19
20 Medical Supplies
25









20
21 Outpatient Services (incl. E/R Dept.)
26









21
22 Radiation Therapy
27









22
23 Chemotherapy
28









23
24 Other
29









24
25 Bereavement Program Costs
30









25
26 Volunteer Program Costs
31









26
27 Fundraising
32









27
28 Other Program Costs
33









28
29 Totals (sum of lines 1-28) (2)











29
30 Unit Cost Multiplier: column 6, line 1 divided by the sum of column 6, line 29











30

minus column 6, line 1, rounded to 6 decimal places.



























(1) Column 0, line 29 must agree with Wkst. A, column 10, line 25.













(2) Columns 0 through 5, line 29 must agree with the corresponding columns of Wkst. B, line 25.
























































































FORM CMS 1728-94-K-5 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3245-3245.1)




























32-331.7












Rev. 13













































Sheet 36: K-5II

05-07


FORM CMS-1728-94





3290 (Cont.)
ALLOCATION OF GENERAL SERVICE




PROVIDER NO:
PERIOD:
WORKSHEET K-5
COSTS TO HOSPICE COST CENTERS




_
FROM: ____________
PART II
STATISTICAL BASIS




HOSPICE NO.:
TO: _______________








_









CAPITAL RELATED PLANT







COST OPERATION

ADMINIS-





BUILDINGS MOVABLE & MAIN-

TRATIVE &

HOSPICE COST CENTER


& FIXTURES EQUIPMENT TENANCE TRANS-
GENERAL





(SQUARE (DOLLAR (SQUARE PORTATION RECONCIL- (ACCUM.





FEET) VALUE) FEET) (MILAGE) IATION COST)





1 2 3 4 5A 5
1 Administrative and General








1
2 Inpatient - General Care








2
3 Inpatient - Respite Care








3
4 Physician Services








4
5 Nursing Care








5
5.20 Nursing Care - Continuous Home Care








5.20
6 Physical Therapy








6
7 Occupational Therapy








7
8 Speech/ Language Pathology








8
9 Medical Social Services - Direct








9
10 Spiritual Counseling








10
11 Dietary Counseling








11
12 Counseling - Other








12
13 Home Health Aide and Homemakers








13
13.20 Home Health Aide and Homemaker-Cont Home Care








13.20
14 Other








14
15 Drugs, Biologicals and Infusion








15
15.30 Analgesics








15.30
15.31 Sedatives/Hypnotics








15.31
15.32 Other - specify








15.32
16 Durable Medical Equipment/Oxygen








16
17 Patient Transportation








17
18 Imaging Services








18
19 Labs and Diagnostics








19
20 Medical Supplies








20
21 Outpatient Services (incl. E/R Dept.)








21
22 Radiation Therapy








22
23 Chemotherapy








23
24 Other








24
25 Bereavement Program Costs








25
26 Volunteer Program Costs








26
27 Fundraising








27
28 Other Program Costs








28
29 Totals (sum of lines 1-28)








29
30 Total cost to be allocated








30
31 Unit Cost Multiplier








31




















































































FORM CMS-1728-94-K-5 (5-2007) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3245.2)






















Rev. 13









32-331.8

Sheet 37: K-5III

3290 (Cont.)



FORM CMS-1728-94




05-07
ALLOCATION OF GENERAL SERVICE



PROVIDER NO.: _____________

PERIOD:
WORKSHEET K-5
COSTS TO HOSPICE COST CENTERS



HOSPICE NO.: ____________

FROM: ___________
Part III
COMPUTATION OF TOTAL HOSPICE SHARED COSTS






TO: ___________


Hospice shared cost computation







Total Hospice







Total HHA Cost to Hospice Shared







Charges Charge Charges Ancillary





From Wkst B, Total HHA (from Provider Ratio (from Provider Costs

COST CENTER


col. 6, line: Costs Records) (col. 2/col.3) Records) (col. 4 x col. 5)





1 2 3 4 5 6
ANCILLARY SERVICE COST CENTERS










1 Physical Therapy


7




1
2 Occupational Therapy


8




2
3 Speech/ Language Pathology


9




3
4 Medical Social Services - Direct


10




4
5 Durable Medical Equipment/Oxygen


14




5
6 Medical Supplies


12




6
7 Totals (sum of lines 1-7)








7




















































































































































































































































































































































































FORM CMS-1728-94-K-5 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3245.3)






















32-331.9









Rev. 13

Sheet 38: K-6

06-01

FORM CMS 1728-94



3290 (Cont.)
CALCULATION OF PER DIEM COST

PROVIDER NO:
PERIOD:
WORKSHEET K-6



_
FROM: ____________





HOSPICE NO.:
TO: _______________





_























COMPUTATION OF PER DIEM COST

TITLE XVIII TITLE XIX OTHER TOTAL




1 2 3 4
1 Total cost (Worksheet K-5, Part I, col. 8, line 29 less col. 8, line 28





1

plus Worksheet K-5, Part III, col. 6, line 7) (see instructions)






2 Total Unduplicated Days (Worksheet S-5, line 5, col. 4)





2
3 Average cost per diem (line 1 divided by line 2)





3
4 Unduplicated Medicare Days (Worksheet S-5, line 5, col. 1)





4
5 Aggregate Medicare cost (line 3 times line 4)





5
6 Unduplicated Medicaid Days (Not Applicable)





6
7 Aggregate Medicaid cost (Not Applicable)





7
8 Unduplicated SNF days (Worksheet S-5, line 5, col. 2)





8
9 Aggregate SNF cost (line 3 times line 8)





9
10 Unduplicated NF days (Not Applicable)





10
11 Aggregate NF cost (Not Applicable)





11
12 Other unduplicated days (Worksheet S-5, line 5, col. 3)





12
13 Aggregate cost for other days (line 3 times line 12)





13


















NOTE: The data for the SNF on line 8 & 9 are included in the Medicare lines 4 & 5.


































































































































































































































































































































FORM CMS-1728-94 (6-2001) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3246)
















Rev. 10






32-331.10

Sheet 39: CM-1 & CM-2

3290 (Cont.)






FORM CMS 1728-94





06-01








PROVIDER NO.:

PERIOD:

WORKSHEET CM-1
ALLOCATION OF GENERAL SERVICE






___________________

FROM: _______________

PARTS I & II
COSTS TO CMHC COST CENTERS






CMHC NO.:

TO: _________________











___________________






PART I - ALLOCATION OF GENERAL SERVICE COSTS TO CMHC COST CENTERS



















NET CAPITAL PLANT



ALLOCATED






EXPENSES RELATED COSTS OPERATION

A&G
CMHC TOTAL

CMHC COST CENTER FOR COST BLDGS & MOVABLE & MAINTE- TRANSPOR- SUBTOTAL SHARED SUB- A&G (SEE (SUM OF

(OMIT CENTS) ALLOCATION (1) FIXTURES EQUIPMENT NANCE TATION (cols. 0-4) COSTS TOTAL PART II) COLS 6 & 7)





0 1 2 3 4 4A 5 6 7 8
1 Administrative and General












1
2 Drugs and Biologicals



#REF!







2
3 Occupational Therapy



#REF!







3
4 Psychiatric/Psychological Services



#REF!







4
5 Individual Therapy



#REF!







5
6 Group Therapy



#REF!







6
7 Family Counseling



#REF!







7
8 Individualized Activity Therapy



#REF!







8
9 Diagnostic Therapy



#REF!







9
10 Patient Training and Education



#REF!







10
11 Other Part B Services












11
12 TOTALS (Sum of lines 1-11) (2)



#REF!







12

(1) Column 0, line 12 must agree with Wkst. A, column 10, line 26.







#REF!





(2) Columns 0 through 5, line 12 must agree with the corresponding columns of Wkst. B, line 26.



































#REF! 0 0 0 0




PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF CMHC ADMINISTRATIVE AND GENERAL COSTS














1 Amount from Part I, column 6, line 12












1
2 Amount from Part I, column 6, line 1












2
3 Line 1 minus line 2












3
4 Unit cost multiplier for CMHC A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,












4

lines 2 through 11, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)













































































































































































































































































FORM CMS 1728-94-CM-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3225-3225.2)






























32-332













Rev. 10
































3290 (Cont.)






FORM CMS 1728-94





03-04








PROVIDER NO.:

PERIOD:

WORKSHEET CM-2
COMPUTATION OF CMHC COSTS






___________________

FROM: _______________











CMHC NO.:

TO: __________________











___________________






PART I - APPORTIONMENT OF CMHC COST CENTERS























RATIO OF
TOTAL TITLE XVIII TITLE XVIII








TOTAL COSTS
COSTS TO TOTAL TITLE XVIII CMHC CMHC COSTS TITLE XVIII







(FROM SUPP. TOTAL CHARGES TITLE XVIII CMHC COSTS CHARGES ON ON OR AFTER CMHC

CMHC COST CENTER



WKST. CM-1, PT. CMHC (COL. 1 / CMHC (COL. 3 x OR AFTER 8/1/00, 1/1/02, COSTS PRIOR

(OMIT CENTS)



I, COL. 8) (1) CHARGES (2) COL. 2) CHARGES COL. 3.01) 8/1/00, 1/1/02, 1/1/03, or 1/1/04 8/1/00, 1/1/02,












1/1/03, or 1/1/04 (COL 3 xCOL. 4) 1/1/03, or 1/1/04







1 2 3 3.01 3.02 4 5 6
1 Administrative and General












1
2 Drugs and Biologicals




100,000 120,000 0.833333 75000 62,500 0 0 62,500 2
3 Occupational Therapy












3
4 Psychiatric/Psychological Services




47,000 59,000 0.796610




4
5 Individual Therapy




52,000 65,000 0.800000




5
6 Group Therapy




26,000 37,000 0.702703




6
7 Family Counseling












7
8 Individualized Activity Therapy












8
9 Diagnostic Therapy












9
10 Patient Training and Education












10
11 Other Part B Services












11
12 TOTALS (Sum of lines 2-11)












12
































PART II - APPORTIONMENT OF COST OF CMHC














SERVICES FURNISHED SHARED BY HHA DEPARTMENTS




Fr. Wkst. B,














Col 6, Line:








13 Occupational Therapy



8







13
14 Medical Social Services



10







14
15 Supplies



12







15
16 Total (Sum of lines 13-15)












16

(1) Cost for Part II, lines 13-15 are obtained from Worksheet B, column 6, lines as appropriate














(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records





























PART III - TOTAL CMHC COSTS








3.01 3.02 4 5 6
17 Total CMHC costs - Add the amount from Part I, column 6, line 12 and the amount from Part II, column 6, line 16.












17

Add the amounts from Part I, line 12 and Part II, line 16 for columns 3.01, 3.02 and 4 through 6, respectively.





























Transfer the amount in Part III, column 6 to Worksheet CM-3, line 1, column 1. (see instructions)














































































































































































FORM CMS 1728-94-CM-2 (3-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3226-3226.3)






























32-334













Rev. 12

Sheet 40: CM-1, PT3

03-04




FORM CMS 1728-94







3290 (Cont.)
ALLOCATION OF GENERAL SERVICE






PROVIDER NO.:

PERIOD:
WORKSHEET CM-1

COSTS TO CMHC COST CENTERS






___________________

FROM: _____________
PART III









CMHC NO.:

TO: ______________











___________________






PART III - ALLOCATION OF GENERAL SERVICE COSTS TO CMHC COST CENTERS - STATISTICAL BASIS

















CAPITAL











RELATED COSTS PLANT













OPERATION









BLDGS & MOVABLE & MAINTE-



ADMINISTRATIVE



FIXTURES EQUIPMENT NANCE TRANSPOR-

& GENERAL

CMHC COST CENTER (SQUARE (SQUARE (SQUARE TATION RECONCIL- (ACCUMULATED

(OMIT CENTS) FEET) FEET) FEET) (MILEAGE) IATION COST)



1 2 3 4 5A 5
1 Administrative and General












1
2 Drugs and Biologicals












2
3 Occupational Therapy












3
4 Psychiatric/Psychological Services












4
5 Individual Therapy












5
6 Group Therapy












6
7 Family Counseling












7
8 Individualized Activity Therapy












8
9 Diagnostic Therapy












9
10 Patient Training and Education












10
11 Other Part B Services












11
12 TOTALS (Sum of lines 1-11)












12
13 Total Cost to be Allocated












13
14 Unit Cost Multiplier












14
































































































































































































































































































































































































































FORM CMS 1728-94-CM-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SEC. 3225.3)






























Rev. 12













32-333

Sheet 41: CM-3

03-04

FORM CMS 1728-94



3290 (Cont.)



PROVIDER NO.: PERIOD:

WORKSHEET CM-3
CALCULATION OF REIMBURSEMENT

___________________ FROM: _______________



SETTLEMENT - CMHC SERVICES

CMHC NO.: TO: _________________





















PART I - COMPUTATION OF THE LESSER OF REASONABLE COST OR CUSTOMARY CHARGES

















DESCRIPTION



1 1.01
1 Total reasonable cost (see instructions)





1
1.01 CMHC PPS payments including outlier payments





1.01
1.02 1996 CMHC specific payment to cost ratio (obtain this ratio from your intermediary)





1.02
1.03 Line 1, column 1 times 1.02





1.03
1.04 Line 1.01 divided by line 1.03





1.04
1.05 CMHC transitional corridor payment (see instructions)





1.05
2 Total charges for CMHC Services





2










CUSTOMARY CHARGES



1 1.01
3 Amounts actually collected from patients liable





3

for payments for services on a charge basis (from







your records)






4 Amount that would have been realized from patients





4

liable for payment for services on a charge basis







had such payment been made in accordance with







42 CFR 413.13(b)






5 Ratio of line 3 to line 4 (not to exceed 1.000000)





5
6 Total Customary charges - title XVIII





6

(see instructions)






7 Excess of total customary charges over total





7

reasonable cost (complete only if line 6







exceeds line 1)






8 Excess of reasonable costs over customary charges





8

(complete only if line 1 exceeds line 6)






9 Primary payer amounts





9




































PART II - COMPUTATION OF REIMBURSEMENT SETTLEMENT




1 1.01
10 Cost of CMHC services (see instructions)





10
11 Part B deductible billed to Program patients (exclude coinsurance amounts)





11
12 Excess of reasonable costs (see instructions)





12
13 Net cost (line10 minus lines 11 and 12)





13
14 80% of Part B cost (80% x line 13) (see instructions)





14
15 Actual coinsurance billed to Program patients (from your records)





15
16 Net cost less actual billed coinsurance (Line 13 minus line 15)





16
17 Reimbursable bad debts (see instructions)





17
18 Net reimbursable amount (see instructions)





18
19 Amounts applicable to prior cost reporting periods resulting from disposition of depreciable assets





19
20 Recovery of excess depreciation resulting from facility's termination or a decrease in Program utilization





20
21 Other adjustments (specify)





21
22 Total Cost (Sum of line 18, columns 1 and 2, minus lines 19 and 20, plus line 21)





22
23 Sequestration adjustment





23
24 Amount due provider (Line 22 minus line 23)





24
25 Interim payments





25
25.5 Tentative settlement (for intermediary use only)





25.5
26 Balance due CMHC/Program (Line 24 minus line 25) (Indicate overpayments in brackets)





26
27 Protested amounts (see instructions)





27
28 Balance due CMHC/Program (Line 26 minus line 27) (Indicate overpayments in brackets)





28



























FORM CMS 1728-94-CM-3 (3-2004) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC.







3227-3227.2)
















Rev. 12






32-335

Sheet 42: CM-4

3290 (Cont.)


FORM CMS 1728-94


03-04
ANALYSIS OF PAYMENTS TO PROVIDER

PROVIDER NO.: PERIOD:

WORKSHEET CM-4
FOR CMHC SERVICES RENDERED

___________________ FROM: _______________



TO PROGRAM BENEFICIARIES

CMHC NO.: TO: _________________



























PART B






1 2






mm/dd/yyyy Amount
1 Total interim payments paid to provider (CMHC services)





1
2 Interim payments payable on individual bills either, submitted or to





2

be submitted to the intermediary, for services rendered in the







cost reporting period. If none, write "NONE" or enter a zero.






3 List separately each retroactive lump sum


.01

3.01

adjustment amount based on subsequent revision

Program .02

3.02

of the interim rate for the cost reporting period.

to .03

3.03

Also show date of each payment. If none write

Provider .04

3.04

"NONE" or enter a zero. (1)


.05

3.05





.50

3.50




Provider .51

3.51




to .52

3.52




Program .53

3.53





.54

3.54

SUBTOTAL (Sum of lines 3.01-3.05, minus sum







of lines 3.50-3.54)


.99

3.99
4 TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)





4

(Transfer to Supp. Wkst CM-3, Part II, line 25)

















TO BE COMPLETED BY INTERMEDIARY









5 List separately each tentative settlement payment

Program .01

5.01

after desk review. Also show date of each

to .02

5.02

payment. If none, write "NONE" or enter

Provider .03

5.03

a zero. (1)

Provider .50

5.50




to .51

5.51




Program .52

5.52

SUBTOTAL (Sum of lines 5.01-5.03, minus sum







of lines 5.50-5.52)


.99

5.99
6 Determine net settlement amount (balance due) based

Program




on the cost report (SEE INSTRUCTIONS). (1)

to







Provider .01

6.01




Provider







to







Program .02

6.02
7 TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)





7









Name of Intermediary



Intermediary Number




















Signature of Authorized Person



Date: (Month, Day, Year)




















(1) On lines 3, 5 and 6, where an amount is due "Provider to Program," show the amount and date on which the provider







agrees to the amount of repayment, even though total repayment is not accomplished until a later date.











































FORM CMS-1728-94-CM-4 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.







PUB. 15-II, SEC. 3228
















32-336






Rev. 12

Sheet 43: RHC

08-99






FORM CMS 1728-94





3290 (Cont.)








PROVIDER NO.:

PERIOD:

WORKSHEET RH-1
ALLOCATION OF GENERAL SERVICE






___________________

FROM: _______________

PARTS I & II
COSTS TO RHC COST CENTERS






RHC NO.:

TO: _________________











___________________






PART I - ALLOCATION OF GENERAL SERVICE COSTS TO RHC COST CENTERS



































NET CAPITAL PLANT



ALLOCATED






EXPENSES RELATED COSTS OPERATION

A&G
RHC TOTAL

CMHC COST CENTER FOR COST BLDGS & MOVABLE & MAINTE- TRANSPOR- SUBTOTAL SHARED SUB- A&G (SEE (SUM OF

(OMIT CENTS) ALLOCATION (1) FIXTURES EQUIPMENT NANCE TATION (cols. 0-4) COSTS TOTAL PART II) COLS 6 & 7)





0 1 2 3 4 4A 5 6 7 8
1 Administrative and General












1
2 Physicians












2
3 Nurse Practitioner












3
4 Physician Assistant












4
5 Clinical Psychologist












5
6 Clinical Social Worker












6
7 Visiting Nurses












7
8 Other Part B Services












8
9













9
10 Drugs Charged to Patients












10
11 TOTALS (Sum of lines 1-10) (2)












11

(1) Column 0, line 11 must agree with Wkst. A, column 10, line 27.














(2) Columns 0 through 5, line 11 must agree with the corresponding columns of Wkst. B, line 27.



































0 0 0 0 0




PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF RHC ADMINISTRATIVE AND GENERAL COSTS














1 Amount from Part I, column 6, line 11












1
2 Amount from Part I, column 6, line 1












2
3 Line 1 minus line 2












3
4 Unit cost multiplier for RHC A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,












4

lines 2 through 10, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)













































































































































































































































































































FORM CMS 1728-94-RH-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3229-3229.2)






























Rev. 7













32-337
08-99






FORM CMS 1728-94





3290 (Cont.)








PROVIDER NO.:

PERIOD:

WORKSHEET RH-2
COMPUTATION OF RHC COSTS






___________________

FROM: _______________











RHC NO.:

TO: __________________











___________________






PART I - APPORTIONMENT OF RHC COST CENTERS








































TOTAL COSTS
RATIO OF
TITLE XVIII

RHC COST CENTER






(FROM SUPP. TOTAL COSTS TO TITLE XVIII RHC COSTS

(OMIT CENTS)






WKST. RH-1, PT. RHC CHARGES RHC (COL. 3 X










I, COL. 8) (1) CHARGES (2) (COL. 1 / COL. 2) CHARGES COL. 4)










1 2 3 4 5
1 Administrative and General












1
2 Physicians












2
3 Nurse Practitioner












3
4 Physician Assistant












4
5 Clinical Psychologist












5
6 Clinical Social Worker












6
7 Visiting Nurses












7
8 Other Part B Services












8
9 Subtotal (sum of lines 1-8)












9
10 Drugs Charged to Patients (Transfer col. 5 to Worksheet D, col. 2, line 20)












10
11 TOTALS (Sum of lines 9 and 10)












11
































PART II - APPORTIONMENT OF COST OF RHC SERVICES FURNISHED BY HHA DEPARTMENTS







Fr. Wkst. B














Col 6, Line:





12 Physical Therapy






7




12
13 Occupational Therapy






8




13
14 Speech Pathology






9




14
15 Supplies






12




15
















17 Total (Sum of lines 12-15)












17

(1) Cost for Part II, lines 12-15 are obtained from Worksheet B, column 6, lines as appropriate














(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records





























PART III - TOTAL RHC COSTS














18 Total RHC costs - Add the amount from Part I, column 5, line 9 and the amounts from Part II, column 5, line 17












18
Transfer the amount in Part III, column 5 to Supplemental Worksheet D, column 3, line 2














































































































































































































FORM CMS 1728-94-RH-2 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3230-3230.3)






























Rev. 7













32-339

Sheet 44: RH-1, PT3

3290 (Cont.)





FORM CMS 1728-94






08-99
ALLOCATION OF GENERAL SERVICE






PROVIDER NO.:

PERIOD:
WORKSHEET RH-1

COSTS TO RHC COST CENTERS






___________________

FROM: _____________
PART III









RHC NO.:

TO: _____________











___________________






PART III - ALLOCATION OF GENERAL SERVICE COSTS TO RHC COST CENTERS - STATISTICAL BASIS

















CAPITAL-











RELATED COSTS PLANT













OPERATION









BLDGS & MOVABLE & MAINTE-



ADMINISTRATIVE



FIXTURES EQUIPMENT NANCE TRANSPOR-

& GENERAL

RHC COST CENTER (SQUARE (SQUARE (SQUARE TATION RECONCIL- (ACCUMULATED

(OMIT CENTS) FEET) FEET) FEET) (MILEAGE) IATION COST)



1 2 3 4 5A 5
1 Administrative and General












1
2 Physicians












2
3 Nurse Practitioner












3
4 Physician Assistant












4
5 Clinical Psychologist












5
6 Clinical Social Worker












6
7 Visiting Nurses












7
8 Other Part B Services












8
9













9
10 Drugs Charged to Patients












10
11 TOTALS (Sum of lines 1-10)












11
12 Total Cost to be Allocated












12
13 Unit Cost Multiplier












13
































































































































































































































































































































































































































FORM CMS 1728-94-RH-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15 -II, SEC. 3229.3)






























32-338













Rev. 7

Sheet 45: FQHC

3290 (Cont.)






FORM CMS 1728-94





08-99








PROVIDER NO.:

PERIOD:

WORKSHEET FQ-1
ALLOCATION OF GENERAL SERVICE






___________________

FROM: _______________

PARTS I & II
COSTS TO FQHC COST CENTERS






FQHC NO.:

TO: _________________











___________________






PART I - ALLOCATION OF GENERAL SERVICE COSTS TO FQHC COST CENTERS



















NET CAPITAL PLANT



ALLOCATED






EXPENSES RELATED COSTS OPERATION

A&G
FQHC TOTAL

FQHC COST CENTER FOR COST BLDGS & MOVABLE & MAINTE- TRANSPOR- SUBTOTAL SHARED SUB- A&G (SEE (SUM OF

(OMIT CENTS) ALLOCATION (1) FIXTURES EQUIPMENT NANCE TATION (cols. 0-4) COSTS TOTAL PART II) COLS 6 & 7)





0 1 2 3 4 4A 5 6 7 8
1 Administrative and General












1
2 Physicians












2
3 Nurse Practitioner












3
4 Physician Assistant












4
5 Clinical Psychologist












5
6 Clinical Social Worker












6
7 Visiting Nurses












7
8 Preventative Primary Services












8
9 Other Part B Services












9
10













10
11 Drugs Charged to Patients












11
12 TOTALS (Sum of lines 1-11) (2)












12

(1) Column 0, line 12 must agree with Wkst. A, column 10, line 28.







#REF!





(2) Columns 0 through 5, line 12 must agree with the corresponding columns of Wkst. B, line 28.



































0 0 0 0 0




PART II - COMPUTATION OF UNIT COST MULTIPLIER FOR ALLOCATION OF FQHC ADMINISTRATIVE AND GENERAL COSTS














1 Amount from Part I, column 6, line 12












1
2 Amount from Part I, column 6, line 1












2
3 Line 1 minus line 2












3
4 Unit cost multiplier for FQHC A&G costs (Line 2 divided by line 3)(multiply each amount in column 6,












4

lines 2 through 11, Part I, by the unit cost multiplier and enter the result on the corresponding line of column 7)













































































































































































































































































































FORM CMS 1728-94-FQ-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3231-3231.2)






























32-340













Rev. 7
3290 (Cont.)






FORM CMS 1728-94





08-99








PROVIDER NO.:

PERIOD:

WORKSHEET FQ-2
COMPUTATION OF FQHC COSTS






___________________

FROM: _______________











FQHC NO.:

TO: __________________











___________________






PART I - APPORTIONMENT OF RHC COST CENTERS








































TOTAL COSTS
RATIO OF
TITLE XVIII

FQHC COST CENTER






(FROM SUPP. TOTAL COSTS TO TITLE XVIII FQHC COSTS

(OMIT CENTS)






WKST. FQ-1, PT. FQHC CHARGES FQHC (COL. 3 X










I, COL. 8) (1) CHARGES (2) (COL. 1 / COL. 2) CHARGES COL. 4)










1 2 3 4 5
1 Administrative and General












1
2 Physicians












2
3 Nurse Practitioner












3
4 Physician Assistant












4
5 Clinical Psychologist












5
6 Clinical Social Worker












6
7 Visiting Nurses












7
8 Preventative Primary Services












8
9 Other Part B Services












9
10 Subtotal (sum of lines 1-9)












10
11 Drugs Charged to Patients (Transfer col. 5 to Worksheet D, col. 2, line 20)












11
12 TOTALS (Sum of lines 10and 11)












12
































PART II - APPORTIONMENT OF COST OF FQHC SERVICES FURNISHED BY HHA DEPARTMENTS







Fr. Wkst. B














Col 6, Line:





13 Physical Therapy






7




13
14 Occupational Therapy






8




14
15 Speech Pathology






9




15
16 Supplies






12




16
















18 Total (Sum of lines 13-16)












18

(1) Cost for Part II, lines 13-16 are obtained from Worksheet B, column 6, lines as appropriate














(2) Charges for Part II, column 2 are total facility charges for each cost center and are obtained from provider records





























PART III - TOTAL FQHC COSTS






























































































































































































































FORM CMS 1728-94-FQ-2 (12-1994) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15-II, SECS. 3232-3232.3)






























32-342













Rev. 7

Sheet 46: FQ-1, PT3

08-99




FORM CMS 1728-94







3290 (Cont.)
ALLOCATION OF GENERAL SERVICE






PROVIDER NO.:

PERIOD:
WORKSHEET FQ-1

COSTS TO FQHC COST CENTERS






___________________

FROM: _____________
PART III









FQHC NO.:

TO: ________________











___________________






PART III - ALLOCATION OF GENERAL SERVICE COSTS TO FQHC COST CENTERS - STATISTICAL BASIS

















CAPITAL-











RELATED COSTS PLANT













OPERATION









BLDGS & MOVABLE & MAINTE-



ADMINISTRATIVE



FIXTURES EQUIPMENT NANCE TRANSPOR-

& GENERAL

FQHC COST CENTER (SQUARE (SQUARE (SQUARE TATION RECONCIL- (ACCUMULATED

(OMIT CENTS) FEET) FEET) FEET) (MILEAGE) IATION COST)



1 2 3 4 5A 5
1 Administrative and General












1
2 Physicians












2
3 Nurse Practitioner












3
4 Physician Assistant












4
5 Clinical Psychologist












5
6 Clinical Social Worker












6
7 Visiting Nurses












7
8 Preventative Primary Services












8
9 Other Part B Services












9
10













10
11 Drugs Charged to Patients












11
12 TOTALS (Sum of lines 1-11)












12
13 Cost to be Allocated












13
14 Unit Cost Multiplier












14
















































































































































































































































































































































































































FORM CMS 1728-94-FQ-1 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.15 -II, SEC. 3231.3)






























Rev. 7













32-341

Sheet 47: RF-1

03-10



FORM CMS 1728-94





3290 (Cont.)
ANALYSIS OF HHA-BASED RURAL HEALTH CLINIC/





PROVIDER NO.:
PERIOD:
WORKSHEET RF-1
FEDERALLY QUALIFIED HEALTH CENTER COSTS





_______________
FROM: ____________









COMPONENT NO.:
TO: ____________









_______________




Check
[ ] RHC









Applicable Box:
[ ] FQHC


















RECLASSIFIED
NET EXPENSES





CONTRACTED/
TOTAL
TRIAL
FOR



EMPLOYEE TRANSPOR- PURCHASED
(sum of col. 1 RECLASSIFI- BALANCE
ALLOCATION


SALARIES BENEFITS TATION SERVICES OTHER COSTS thru col. 5) CATIONS (col. 6 + col. 7) ADJUSTMENTS (col. 8 + col. 9)


1 2 3 4 5 6 7 8 9 10
FACILITY HEALTH CARE STAFF COSTS









1 Physician









1
2 Physician Assistant









2
3 Nurse Practitioner









3
4 Visiting Nurse









4
5 Other Nurse









5
6 Clinical Psychologist









6
7 Clinical Social Worker









7
8 Laboratory Technician









8
9 Other Facility Health Care Staff Costs









9
10 Subtotal (sum of lines 1-9)









10
COSTS UNDER AGREEMENT









11 Physician Services Under Agreement









11
12 Physician Supervision Under Agreement









12
13 Other Costs Under Agreement









13
14 Subtotal (sum of lines 11-13)









14
OTHER HEALTH CARE COSTS









15 Medical Supplies









15
16 Transportation (Health Care Staff)









16
17 Depreciation-Medical Equipment









17
18 Professional Liability Insurance









18
19 Other Health Care Costs









19
20 Allowable GME Pass Through Costs









20
21 Subtotal (sum of lines 15-20)









21
22 Total Cost of Health Care Services (sum of









22

lines 10, 14, and 21)











COSTS OTHER THAN RHC/FQHC SERVICES










23 Pharmacy









23
24 Dental









24
25 Optometry









25
26 All other nonreimbursable costs









26
27 Non-allowable GME Pass Through Costs









27
28 Total Nonreimbursable Costs (sum of lines 23-27)









28

FACILITY OVERHEAD










29 Facility Costs









29
30 Administrative Costs









30
31 Total Facility Overhead (sum of lines 29 and 30)









31
32 Total facility costs (sum of lines 22, 28 and 31)









32

The net expenses for cost allocation on Worksheet A for the applicable RHC/FQHC cost center line must equal the total facility costs in column 10, line 30 of this worksheet for cost reporting











periods beginning on or after January 1, 1998.























FORM CMS-1728-94-RF-1 (3-2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3234)
























Rev. 15



32-343

Sheet 48: RF-2

3290 (Cont.)

FORM CMS 1728-94


01-10
ALLOCATION OF OVERHEAD
PROVIDER NO.:
PERIOD:
WORKSHEET RF-2
TO RHC/FQHC SERVICES
_______________
FROM: ____________




COMPONENT NO.:
TO: ____________




_______________




Check
[ ] RHC




Applicable Box:
[ ] FQHC




VISITS AND PRODUCTIVITY
















Number

Minimum Greater of


of FTE Total Productivity Visits Col. 2 or


Personnel Visits Standard (1) (col. 1x col. 3) Col. 4

Positions 1 2 3 4 5
1 Physicians




1
2 Physician Assistants




2
3 Nurse Practitioners




3
4 Subtotal (sum of lines 1-3)




4
5 Visiting Nurse




5
6 Clinical Psychologist




6
7 Clinical Social Worker




7
8 Total FTEs and Visits (sum of lines 4-7)




8
9 Physician Services Under Agreements




9

(1) Productivity standards established by CMS are: 4200 visits for each physician and 2100 visits for each nonphysician






practitioner. If an exception to the productivity standard has been granted, (Worksheet S-4, line 13 equals "Y"), then input






in column 3, lines 1-3, the productivity standards derived by the fiscal intermediary.













DETERMINATION OF ALLOWABLE COST APPLICABLE TO RHC/FQHC SERVICES






10 Total costs of health care services (from Worksheet RF-1, column 10, line 22 less the amount




10

from Worksheet RF-1, column 10, line 20)





11 Total nonreimbursable costs (from Worksheet RF-1, column 10, line 28)




11
12 Cost of all services (excluding overhead) (sum of lines 10 and 11)




12
13 Ratio of RHC/FQHC services (line 10 divided by line 12)




13
14 Total facility overhead - (from Worksheet RF-1, column 10, line 31) (see instructions)




14
15 Allowable GME Overhead (see instructions)




15
16 Net Facility Overhead (line 14 minus line 15)




16
17 Parent provider overhead allocated to facility (see instructions)




17
18 Total overhead (sum of lines 14 and 17)




18
19 Overhead applicable to RHC/FQHC services (line 13 x line 18)




19
20 Total allowable cost of RHC/FQHC services (sum of lines 10 and 19)




20
















































































































FORM CMS-1728-94-RF-2 (3-2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.






15-II, SECTION 3235 - 3235.2)














32-344



Rev. 15

Sheet 49: RF-3

01-10
FORM CMS 1728-94


3290 (Cont.)
CALCULATION OF
PROVIDER NO.: PERIOD:
WORKSHEET RF-3
REIMBURSEMENT SETTLEMENT
_______________ FROM: ___________


FOR RHC/FQHC SERVICES
COMPONENT NO.: TO: ___________




_______________



Check
[ ] RHC



Applicable Box:
[ ] FQHC



DETERMINATION OF RATE FOR RHC/FQHC SERVICES





1 Total Allowable Cost of RHC/FQHC Services (from Worksheet RF-2, line 20)



1
2 Cost of vaccines and their administration (from Worksheet RF-4, line 15)



2
3 Total allowable cost excluding vaccine (line 1 minus line 2)



3
4 Total FTEs and Visits (from Wkst. RF-2, col. 5, line 8)



4
5 Physicians visits under agreement (from Worksheet RF-2, column 5, line 9)



5
6 Total adjusted visits (line 4 plus line 5)



6
7 Adjusted cost per visit (line 3 divided by line 6)



7










Calculation of Limit (1)



Rate Rate Rate



Period 1 Period 2 Period 3



1 2 3
8 Per visit payment limit (from your intermediary)



8
9 Rate for Medicare covered visits (lesser of line 7 or line 8) (See instructions)



9







CALCULATION OF SETTLEMENT





10 Medicare covered visits excluding mental health services



10

(from intermediary records)




11 Medicare cost excluding costs for mental health services



11

(line 9 x line 10)




12 Medicare covered visits for mental health services



12

(from intermediary records)




13 Medicare covered cost for mental health services (line 9 x line 12)



13
14 Limit adjustment for mental health services



14

(line 13 x the applicable percentage) (see instructions)
















1
15 Graduate Medical Education Pass Through Cost (see instructions)



15
15.5 Primary Payer Amounts



15.5
16 Total Medicare cost (line 11, columns 1, 2 & 3 plus line 14, columns 1, 2, & 3 plus column



16

1, line 15 minus \line 15.5)




17 Less: Beneficiary deductible (from intermediary records)



17
18 Net Medicare cost excluding vaccines (line 16 minus line 17)



18
19 Reimbursable cost of RHC/FQHC services, excluding vaccine (80% of line 18)



19
20 Medicare cost of vaccines and their administration (from Worksheet. RF-4, line 16)



20
21 Total reimbursable Medicare cost (line 19 plus line 20)



21
22 Reimbursable bad debts



22
23 Other adjustments (specify)



23
24 Net reimbursable amounts (sum of lines 21, 22 and 23)



24
25 Interim payments (From Worksheet RF-5, line 4)



25
25.5 Tentative settlement (For intermediary use only)



25.5
26 Balance due component/program (line 24 minus line 25)



26
27 Protested amounts (nonallowable cost report items) in accordance with CMS Pub.



27

15-II, chapter I, section 115.2











(1) Enter chronologically in columns 1, 2, and 3, as applicable, the payment limit and corresponding data.












FORM CMS-1728-94-RF-3 (1-2010) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB.





15-II, SECTIONS 3236 - 3236.1)












Rev. 14


32-345

Sheet 50: RF-4

3290 (Cont.)


FORM CMS 1728-94

01-10
COMPUTATION OF PNEUMOCOCCAL AND


PROVIDER NO.: PERIOD: WORKSHEET RF-4
INFLUENZA VACCINE COST


_______________ FROM: _______





COMPONENT NO.: TO: __________





_______________


Check
[ ] RHC




Applicable Box:
[ ] FQHC
















SEASONAL
INFLUENZA




INFLUENZA H1N1 & H1N1



PNEUMOCOCCAL ONLY ONLY (See instructions)

CALCULATION OF COST
1 2 2.01 2.02
1 Health care staff cost




1

(Worksheet RF-1, column 10, line 10)





2 Ratio of pneumococcal and influenza vaccine




2

staff time to total health care staff time





3 Pneumococcal and influenza vaccine




3

health care staff cost (line 1 x line 2)





4 Medical supplies cost - pneumococcal and influenza




4

vaccine (from your records)





5 Direct cost of pneumococcal and influenza




5

vaccine (line 3 plus line 4)





6 Total direct cost of the facility




6

(Worksheet RF-1, column 10, line 22)





7 Total facility overhead




7

(Worksheet RF-2, line 18)





8 Ratio of pneumococcal and influenza vaccine




8

direct cost to total direct cost (line 5 divided by line 6)





9 Overhead cost - pneumococcal and influenza




9

vaccine (line 7 x line 8)





10 Total pneumococcal and influenza vaccine cost and




10

its (their) administration (sum of lines 5 and 9)





11 Total number of pneumococcal and influenza




11

vaccine injections (from your records)





12 Cost per pneumococcal and influenza




12

vaccine injection (line 10/ line 11)





13 Number of pneumococcal and influenza vaccine




13

injections administered to Medicare beneficiaries





14 Medicare cost of pneumococcal and influenza vaccine




14

and its (their) administration (line 12 x line 13)













15 Total cost of pneumococcal and influenza vaccine and its (their) administration (sum of columns




15

1, 2, 2.01 and 2.02, line 10) (transfer this amount to Worksheet RF-3, line 2)





16 Total Medicare cost of pneumococcal and influenza vaccine and its (their) administration (sum




16

of columns 1, 2, 2.01 and 2.02, line 14) (transfer this amount to Worksheet RF-3, line 20)




























































































































































































FORM CMS-1728-94-RF-4 (1-2010) (INSTRUCTIONS FOR THIS FORM ARE PUBLISHED IN CMS PUB. 15-II, SECTION 3237)






















32-346




Rev. 14

Sheet 51: RF-5

08-99

FORM CMS 1728-94



3290 (Cont.)
ANALYSIS OF PAYMENTS TO PROVIDER-BASED


PROVIDER NO.:
PERIOD: SUPPLEMENTAL
RHC/FQHC FOR SERVICES RENDERED TO


_______________
FROM: __________ WORKSHEET RF-5
PROGRAM BENEFICIARIES


COMPONENT NO.:
TO: __________





_______________



Check Applicable Box:

[ ] RHC [ ] FQHC










PART B

DESCRIPTION


1 2






mm/dd/yyyy Amount
1 Total interim payments paid to RHC/FQHC





1
2 Interim payments payable on individual bills either, submitted or to





2

be submitted to the intermediary, for services rendered in the







cost reporting period. If none, write "NONE" or enter a zero.






3 List separately each retroactive lump sum


.01

3.01

adjustment amount based on subsequent revision

Program .02

3.02

of the interim rate for the cost reporting period.

to .03

3.03

Also show date of each payment. If none write

Provider .04

3.04

"NONE" or enter a zero. (1)


.05

3.05





.50

3.50




Provider .51

3.51




to .52

3.52




Program .53

3.53





.54

3.54

SUBTOTAL (Sum of lines 3.01-3.49, minus sum







of lines 3.50-3.98)


.99

3.99
4 TOTAL INTERIM PAYMENTS (Sum of lines 1, 2 and 3.99)





4

(Transfer to Supp. Wkst RF-3, Part II, line 25)

















TO BE COMPLETED BY INTERMEDIARY









5 List separately each tentative settlement payment

Program .01

5.01

after desk review. Also show date of each

to .02

5.02

payment. If none, write "NONE" or enter

Provider .03

5.03

a zero. (1)

Provider .50

5.50




to .51

5.51




Program .52

5.52

SUBTOTAL (Sum of lines 5.01-5.49, minus sum







of lines 5.50-5.98)


.99

5.99
6 Determine net settlement amount (balance due) based

Program




on the cost report (SEE INSTRUCTIONS). (1)

to







Provider .01

6.01




Provider







to







Program .02

6.02
7 TOTAL MEDICARE PROGRAM LIABILITY (See Instructions)





7









Name of Intermediary



Intermediary Number




















Signature of Authorized Person



Date: (Month, Day, Year)




















(1) On lines 3, 5 and 6, where an amount is due "Provider to Program," show the amount and date on which the provider







agrees to the amount of repayment, even though total repayment is not accomplished until a later date.

































































































FORM CMS-1728-94-RF-5 (11-1998) (INSTRUCTIONS FOR THIS WORKSHEET ARE PUBLISHED IN CMS PUB. 15-II, SEC. 3238
















Rev. 7






32-347
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