Form CMS-1728-94 Medicare Cost Report Forms

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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