Crosswalk for Revisions Final Cost Report 4-2013vj 508

Revisions Crosswalk (Form 276-08)
Final Cost Report
Note: In Changes to the Application column, the quoted words are what are to be entered. Example in issue #7 is “Physician Group:” where it is also
explained that it must be in bold.
Issue
#
1.

2.

3.

4.

Page #

Section

Work
Sheet
D, Part
I, Page
1
Work
Sheet
D, Part
I, Page
1
Work
Sheet
D, Part
I, Page
2
Work
Sheet
D, Part
I, Page
2

Column 6,
Titled
”Medicare
Primary
Days”
Column 7,
Titled
”Medicare
Secondary
Days”
Column 6,
Titled
”Medicare
Primary
Visits”
Column 7,
Titled
”Medicare
Secondary
Visits”

Action to be
performed
Change Title to read:

Changes to the Application

Reason for the Change

“Cov Med Primary Days”

This is a CMS change of language
to better reflect the number of days
that should be included in the cost
report.

Change Title to read:

“Cov Med Secondary Days”

This is a CMS change of language
to better reflect the number of days
that should be included in the cost
report.

Change Title to read:

“Cov Med Primary Visits”

This is a CMS change of language
to better reflect the number of
visits that should be included in
the cost report.

Change Title to read:

“Cov Med Secondary Visits”

This is a CMS change of language
to better reflect the number of
visits that should be included in
the cost report.

Page 1 of 26

Issue
#
5.

6.

7.

8.

Page #

Section

Work
Sheet
D, Part
II,
Page 1

Column 6,
Titled
”Medicare
Primary”

Work
Sheet
D, Part
II,
Page 1
Work
Sheet
D, Part
II,
Page 1

Work
Sheet
D, Part
II,
Page 1

Action to be
performed
Change Title to read:

Changes to the Application

Reason for the Change

“Covered Med Primary”

This is a CMS change of language
to better reflect the number of
visits that should be included in
the cost report.

Column 7,
Titled
”Medicare
Secondary”

Change Title to read:

“Covered Med Secondary”

This is a CMS change of language
to better reflect the number of days
that should be included in the cost
report.

Column
Titled “List
Of
Suppliers”,
Section A.
Physician
Services:
Line 41
Line 41,
Columns 1-7.

Add Wording:

“Physician Groups” (In Bold)

To reflect CMS’ decision to sum
up all statistics for the different
Physician Groups, this is the title
of this grouping.

Add block of grey:

This entire line should be blocked out grey from
Column 1 to Column 7.

To reflect CMS’ decision to sum
up all statistics for the different
Physician Groups statistics related
to this line, this is the title of this
grouping, so there should be no
area for plan input.

Page 2 of 26

Issue
#
9.

Page #

Section

Work
Sheet
D, Part
II,
Page 1

Column
Titled “List
Of
Suppliers”,
Section A.
Physician
Services:
Line 42
Line 42,
Columns 1-3

Action to be
performed
Add Wording:

Changes to the Application

Reason for the Change

“Fee For Service”

To reflect CMS’ decision to sum
up all statistics for the different
Physician Groups statistics related
to this line, this is the title of this
group.

Add block of grey:

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different
Physician Groups statistics related
to this line, these columns are not
in use, so there should be no area
for plan input.
This line now sums up the common statistics in these
To reflect CMS’ decision to sum
columns. These lines and columns are now hard coded up all statistics for the different
and protected.
Physician Groups statistics related
to this line, this line represents the
sum of all similar statistics for Fee
For Service.

10.

Work
Sheet
D, Part
II,
Page 1

11.

Work
Sheet
D, Part
II,
Page 1

Line 42,
Columns 4-7

Change Formula:

12.

Work
Sheet
D, Part
II,
Page 1

Add Wording:

“Capitation”

13.

Work
Sheet
D, Part
II,
Page 1

Column
Titled “List
Of
Suppliers”,
Section A.
Physician
Services:
Line 43
Line 43,
Columns 1-3

Add block of grey:

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different
Physician Groups statistics related
to this line, these columns are not
in use, so there should be no area

To reflect CMS’ decision to sum
up all statistics for the different
Physician Groups statistics related
to this line, this is the title of this
group.

Page 3 of 26

Issue
#

Page #

Section

Action to be
performed

Changes to the Application

Reason for the Change

14.

Work
Sheet
D, Part
II,
Page 1

Line 43,
Columns 4-7

Change Formula:

This line now sums up the common statistics in these
columns. These lines and columns are now hard coded
and protected.

15.

Work
Sheet
D, Part
II,
Page 1

Add Wording:

“Other”

16.

Work
Sheet
D, Part
II,
Page 1

Column
Titled “List
Of
Suppliers”,
Section A.
Physician
Services:
Line 44
Line 44,
Columns 1-3

Add block of grey:

17.

Work
Sheet
D, Part
II,
Page 1

Line 44,
Columns 4-7

Change Formula:

18.

Work
Sheet
D, Part
II,
Page 1

Column
Titled “List
Of
Suppliers”,
Section A.
Physician

Add Wording:

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different
Physician Groups statistics related
to this line, these columns are not
in use, so there should be no area
for plan input.
This line now sums up the common statistics in these
To reflect CMS’ decision to sum
columns. These lines and columns are now hard coded up all statistics for the different
and protected.
Physician Groups statistics related
to this line, this line represents the
sum of all similar statistics for
Other.
“Individual Physicians” (In Bold)
To reflect CMS’ decision to sum
up all statistics for the different
Individual Physicians statistics
related to this line, this is the title
of this grouping.

for plan input.
To reflect CMS’ decision to sum
up all statistics for the different
Physician Groups statistics related
to this line, this line represents the
sum of all similar statistics for
Capitation.
To reflect CMS’ decision to sum
up all statistics for the different
Physician Groups statistics related
to this line, this is the title of this
group.

Page 4 of 26

Issue
#

Page #

Section
Services:
Line 45
Column
Titled “List
Of
Suppliers”,
Section A.
Physician
Services:
Line 45
Column
Titled “List
Of
Suppliers”,
Section A.
Physician
Services:
Line 46
Line 46,
Columns 1-3

Action to be
performed

Changes to the Application

Reason for the Change

Add block of grey:

This entire line should be blocked out grey from
Column 1 to Column 7.

To reflect CMS’ decision to sum
up all statistics for the different
Individual Physicians statistics
related to this line, this is the title
of this grouping, so there should
be no area for plan input.

Add Wording:

“Fee For Service”

To reflect CMS’ decision to sum
up all statistics for the different
Individual Physicians statistics
related to this line, this is the title
of this group.

Add block of grey:

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different
Individual Physicians statistics
related to this line, these columns
are not in use, so there should be
no area for plan input.
This line now sums up the common statistics in these
To reflect CMS’ decision to sum
columns. These lines and columns are now hard coded up all statistics for the different
and protected.
Individual Physicians statistics
related to this line, this line
represents the sum of all similar
statistics for Fee For Service.
“Capitation”
To reflect CMS’ decision to sum
up all statistics for the different
Individual Physicians statistics

19.

Work
Sheet
D, Part
II,
Page 1

20.

Work
Sheet
D, Part
II,
Page 1

21.

Work
Sheet
D, Part
II,
Page 1

22.

Work
Sheet
D, Part
II,
Page 1

Line 46,
Columns 4-7

Change Formula:

23.

Work
Sheet
D, Part

Column
Titled “List
Of

Add Wording:

Page 5 of 26

Issue
#

Page #

Section

II,
Page 1

Suppliers”,
Section A.
Physician
Services:
Line 47
Line 47,
Columns 1-3

Action to be
performed

Changes to the Application

Reason for the Change
related to this line, this is the title
of this group.

24.

Work
Sheet
D, Part
II,
Page 1

Add block of grey:

25.

Work
Sheet
D, Part
II,
Page 1

Line 47,
Columns 4-7

Change Formula:

26.

Work
Sheet
D, Part
II,
Page 1

Add Wording:

27.

Work
Sheet
D, Part
II,
Page 1

Column
Titled “List
Of
Suppliers”,
Section A.
Physician
Services:
Line 48
Line 48,
Columns 1-3

28.

Work
Sheet

Line 48,
Columns 4-7

Change Formula:

Add block of grey:

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different
Individual Physicians statistics
related to this line, these columns
are not in use, so there should be
no area for plan input.
This line now sums up the common statistics in these
To reflect CMS’ decision to sum
columns. These lines and columns are now hard coded up all statistics for the different
and protected.
Individual Physicians statistics
related to this line, this line
represents the sum of all similar
statistics for Capitation.
“Other”
To reflect CMS’ decision to sum
up all statistics for the different
Individual Physicians statistics
related to this line, this is the title
of this group.

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different
Individual Physicians statistics
related to this line, these columns
are not in use, so there should be
no area for plan input.
This line now sums up the common statistics in these
To reflect CMS’ decision to sum
columns. These lines and columns are now hard coded up all statistics for the different

Page 6 of 26

Issue
#

Page #

Section

Action to be
performed

D, Part
II,
Page 1

Changes to the Application

Reason for the Change

and protected.

Individual Physicians statistics
related to this line, this line
represents the sum of all similar
statistics for Other.
This is a CMS change of language
to better reflect the number of days
that should be listed in the cost
report.

29.

Work
Sheet
D, Part
II,
Page 2

Column 6,
Titled
”Medicare
Primary”

Change Title to read:

“Covered Med Primary”

30.

Work
Sheet
D, Part
II,
Page 2

Column 7,
Titled
”Medicare
Secondary”

Change Title to read:

“Covered Med Secondary”

This is a CMS change of language
to better reflect the number of days
that should be listed in the cost
report.

31.

Work
Sheet
D, Part
II,
Page 2

Column
Add Wording:
Titled “List
Of Suppliers”
Section B.
Certified
Labs: Line 8

“Certified Labs” (In Bold)

To reflect CMS’ decision to sum
up all statistics for the different
Certified Labs statistics related to
this line, this is the title of this
group.

32.

Work
Sheet
D, Part
II,
Page 2

Section B.
Certified
Labs: Line 8,
Columns 1-7

Add block of grey:

This entire line should be blocked out grey from
Column 1 to Column 7.

To reflect CMS’ decision to sum
up all statistics for the different
Certified Lab statistics related to
this line, these columns are not in
use, so there should be no area for
plan input.

33.

Work

Column

Add Wording:

“Fee For Service”

To reflect CMS’ decision to sum

Page 7 of 26

Issue
#

Page #

Section

Action to be
performed

Sheet
D, Part
II,
Page 2

Titled “List
Of Suppliers”
Section B.
Certified
Labs: Line 9
Section B.
Add block of grey:
Certified
Labs: Line 9,
Columns 1-3

34.

Work
Sheet
D, Part
II,
Page 2

35.

Work
Sheet
D, Part
II,
Page 2

Section B.
Certified
Labs: Line 9,
Columns 4-7

36.

Work
Sheet
D, Part
II,
Page 2

37.

Work
Sheet
D, Part
II,
Page 2

Column
Add Wording:
Titled “List
Of Suppliers”
Section B.
Certified
Labs: Line 10
Section B.
Add block of grey:
Certified
Labs: Line
10, Columns
1-3

Change Formula:

Changes to the Application

Reason for the Change
up all statistics for the different
Certified Lab statistics related to
this line, this is the title of this
group.

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different
Certified Lab statistics related to
this line, these columns are not in
use, so there should be no area for
plan input.
This line now sums up the common statistics in these
To reflect CMS’ decision to sum
columns. These lines and columns are now hard coded up all statistics for the different
and protected.
Certified Lab statistics related to
this line, this line represents the
sum of all similar statistics for Fee
For Service.

“Capitation”

To reflect CMS’ decision to sum
up all statistics for the different
Certified Lab statistics related to
this line, this is the title of this
group.

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different
Certified Lab statistics related to
this line, these columns are not in
use, so there should be no area for
plan input.

Page 8 of 26

Issue
#
38.

Page #

Section

Work
Sheet
D, Part
II,
Page 2

Section B.
Certified
Labs: Line
10, Columns
4-7

39.

Work
Sheet
D, Part
II,
Page 2

40.

41.

Action to be
performed
Change Formula:

Changes to the Application

Reason for the Change

This line now sums up the common statistics in these
columns. These lines and columns are now hard coded
and protected.

To reflect CMS’ decision to sum
up all statistics for the different
Certified Lab statistics related to
this line, this line represents the
sum of all similar statistics for
Capitation.

“Other”

To reflect CMS’ decision to sum
up all statistics for the different
Certified Lab statistics related to
this line, this is the title of this
group.

Work
Sheet
D, Part
II,
Page 2

Column
Add Wording:
Titled “List
Of Suppliers”
Section B.
Certified
Labs: Line 11
Section B.
Add block of grey:
Certified
Labs: Line
11, Columns
1-3

Work
Sheet
D, Part
II,
Page 2

Section B.
Certified
Labs: Line
11, Columns
4-7

This line now sums up the common statistics in these
columns. These lines and columns are now hard coded
and protected.

Change Formula:

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different
Certified Lab statistics related to
this line, these columns are not in
use, so there should be no area for
plan input.

To reflect CMS’ decision to sum
up all statistics for the different
Certified Lab statistics related to
this line, this line represents the
sum of all similar statistics for
Other.

Page 9 of 26

Issue
#
42.

Page #

Section

Work
Sheet
D, Part
II,
Page 2

Column
Titled “List
Of
Suppliers”,
Section C. XRay Units:
Line 8
Section C. XRay Units:
Line 8,
Columns 1-7

43.

Work
Sheet
D, Part
II,
Page 2

44.

Work
Sheet
D, Part
II,
Page 2

45.

Work
Sheet
D, Part
II,
Page 2

46.

Work
Sheet
D, Part
II,
Page 2

Action to be
performed
Add Wording:

Changes to the Application

Reason for the Change

“X-Ray Units” (In Bold)

To reflect CMS’ decision to sum
up all statistics for the different XRay Unit statistics related to this
line, this is the title of this group.

Add block of grey:

This entire line should be blocked out grey from
Column 1 to Column 7.

To reflect CMS’ decision to sum
up all statistics for the different XRay Unit statistics related to this
line, these columns are not in use,
so there should be no area for plan
input.
To reflect CMS’ decision to sum
up all statistics for the different XRay Unit statistics related to this
line, this is the title of this group.

Column
Add Wording:
Titled “List
Of Suppliers”
Section C. XRay Units:
Line 9
Section C. X- Add block of grey:
Ray Units:
Line 9,
Columns 1-3

“Fee For Service”

Section C. XRay Units:
Line 9,
Columns 4-7

This line now sums up the common statistics in these
columns. These lines and columns are now hard coded
and protected.

Change Formula:

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different XRay Unit statistics related to this
line, these columns are not in use,
so there should be no area for plan
input.

To reflect CMS’ decision to sum
up all statistics for the different XRay Unit statistics related to this
line, this line represents the sum of
all similar statistics for Fee For
Service.

Page 10 of 26

Issue
#
47.

Page #

Section

Work
Sheet
D, Part
II,
Page 2

Column
Titled “List
Of Suppliers”
Section C. XRay Units:
Line 10
Section C. X- Add block of grey:
Ray Units:
Line 10,
Columns 1-3

48.

Work
Sheet
D, Part
II,
Page 2

49.

Work
Sheet
D, Part
II,
Page 2
Work
Sheet
D, Part
II,
Page 2

Section C. XRay Units:
Line 10,
Columns 4-7

Work
Sheet
D, Part
II,
Page 2

Section C. XRay Units:
Line 11,
Columns 1-3

50.

51.

Action to be
performed
Add Wording:

Change Formula:

Column
Add Wording:
Titled “List
Of Suppliers”
Section C. XRay Units:
Line 11

Add block of grey:

Changes to the Application

Reason for the Change

“Capitation”

To reflect CMS’ decision to sum
up all statistics for the different XRay Unit statistics related to this
line, this is the title of this group.

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different XRay Unit statistics related to this
line, these columns are not in use,
so there should be no area for plan
input.
This line now sums up the common statistics in these
To reflect CMS’ decision to sum
columns. These lines and columns are now hard coded up all statistics for the different Xand protected.
Ray Unit statistics related to this
line, this line represents the sum of
all similar statistics for Capitation.
“Other”
To reflect CMS’ decision to sum
up all statistics for the different XRay Unit statistics related to this
line, this is the title of this group.

This line should be blocked out grey from Column 1 to To reflect CMS’ decision to sum
Column 3.
up all statistics for the different XRay Unit statistics related to this
line, these columns are not in use,
so there should be no area for plan
input.

Page 11 of 26

Issue
#
52.

Action to be
performed
Change Formula:

Changes to the Application

Reason for the Change

This line now sums up the common statistics in these
columns. These lines and columns are now hard coded
and protected.

Column
Titled “Cost
Center” ,
Line 19
Work Column
Sheet E Titled “Cost
Center”, Line
20
Work Column 7,
Sheet E Line 19

Change line to read:

“Part B Costs Not Subject to Coinsurance”

To reflect CMS’ decision to sum
up all statistics for the different XRay Unit statistics related to this
line, this line represents the sum of
all similar statistics for Other.
To reflect CMS’ 100% covered
services/drugs that exclude
beneficiary coinsurance.

Change line to read:

“Non-Allowable Costs”

56.

Work
Sheet E

Column 7,
Line 20

Change to:

Block out grey for the entire line. This should look
exactly like Column 7, line 13on the same worksheet.

57.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 3

Change to read:

“Fee For Service………………….”

58.

Work
Sheet K

Line 3,
Columns 2-4

Change of formula:

These columns are now protected and pull the
information directly from Work Sheet D.

53.

54.

55.

Page #

Section

Work
Sheet
D, Part
II,
Page 2
Work
Sheet E

Section C. XRay Units:
Line 11,
Columns 4-7

Change space to:

L │ 25

To reflect CMS’ decision to
provide a line for reporting NonAllowable costs.
To allow the costs to flow to the
proper Worksheet L, Column 2,
Line 25.
This cost center is not reimbursed
and does not transfer to another
sheet.
To reflect CMS’s changes to Work
Sheet D.

To reflect CMS’s changes to Work
Sheet D.

Page 12 of 26

Issue
#
59.

Page #

Section

Action to be
performed
Change to read:

Changes to the Application

Reason for the Change

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 4

“Capitation……………………..”

To reflect CMS’s changes to Work
Sheet D.

60.

Work
Sheet K

Line 4,
Columns 2-4

Change of formula:

These columns are now protected and pull the
information directly from Work Sheet D.

To reflect CMS’s changes to Work
Sheet D.

61.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 5

Change to read:

“Other………………………”

To reflect CMS’s changes to Work
Sheet D.

62.

Work
Sheet K

Line 5,
Columns 2-4

Change of formula:

These columns are now protected and pull the
information directly from Work Sheet D.

To reflect CMS’s changes to Work
Sheet D.

63.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 6

Change to read:

“Individual Physicians:” (In Bold)

To reflect CMS’s changes to Work
Sheet D.

Page 13 of 26

Issue
#
64.

Page #

Section

Action to be
performed
Change to:

Changes to the Application

Reason for the Change

Work
Sheet K

Line 6,
Columns 1-7

Block out grey for the entire line. This should look
exactly like line 2, Columns 1-7 on the Work Sheet K.

This cost center is not reimbursed
and does not transfer to another
sheet.

65.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 7

Change to read:

“Fee For Service………………….”

To reflect CMS’s changes to Work
Sheet D.

66.

Work
Sheet K

Line 7,
Columns 2-4

Change of formula:

These columns are now protected and pull the
information directly from Work Sheet D.

To reflect CMS’s changes to Work
Sheet D.

67.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 8

Change to read:

“Capitation……………………..”

To reflect CMS’s changes to Work
Sheet D.

68.

Work
Sheet K

Line 8,
Columns 2-4

Change of formula:

These columns are now protected and pull the
information directly from Work Sheet D.

To reflect CMS’s changes to Work
Sheet D.

Page 14 of 26

Issue
#
69.

Page #

Section

Action to be
performed
Change to read:

Changes to the Application

Reason for the Change

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 9

“Other………………………”

To reflect CMS’s changes to Work
Sheet D.

70.

Work
Sheet K

Line 9,
Columns 2-4

Change of formula:

These columns are now protected and pull the
information directly from Work Sheet D.

To reflect CMS’s changes to Work
Sheet D.

71.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 10

Change to read:

“Certified Labs:” (In Bold)

To reflect CMS’s changes to Work
Sheet D.

72.

Work
Sheet K

Line 10,
Columns 1-7

Change to:

Block out grey for the entire line. This should look
exactly like line 2, Columns 1-7 on the Work Sheet K.

This cost center is not reimbursed
and does not transfer to another
sheet.

73.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 11

Change to read:

“Fee For Service………………….”

To reflect CMS’s changes to Work
Sheet D.

Page 15 of 26

Issue
#
74.

Page #

Section

Action to be
performed
Change of formula:

Changes to the Application

Reason for the Change

Work
Sheet K

Line 11,
Columns 2-4

These columns are now protected and pull the
information directly from Work Sheet D.

To reflect CMS’s changes to Work
Sheet D.

75.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 12

Change to read:

“Capitation……………………..”

To reflect CMS’s changes to Work
Sheet D.

76.

Work
Sheet K

Line 12,
Columns 2-4

Change of formula:

These columns are now protected and pull the
information directly from Work Sheet D.

To reflect CMS’s changes to Work
Sheet D.

77.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 13

Change to read:

“Other………………………”

To reflect CMS’s changes to Work
Sheet D.

78.

Work
Sheet K

Line 13,
Columns 2-4

Change of formula:

These columns are now protected and pull the
information directly from Work Sheet D.

To reflect CMS’s changes to Work
Sheet D.

Page 16 of 26

Issue
#
79.

Page #

Section

Action to be
performed
Change to read:

Changes to the Application

Reason for the Change

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 14

“X-Ray Units:” (In Bold)

To reflect CMS’s changes to Work
Sheet D.

80.

Work
Sheet K

Line 14,
Columns 1-7

Change to:

Block out gray for the entire line. This should look
exactly like line 2, Columns 1-7 on the Work Sheet K.

This cost center is not reimbursed
and does not transfer to another
sheet.

81.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 15

Change to read:

“Fee For Service………………….”

To reflect CMS’s changes to Work
Sheet D.

82.

Work
Sheet K

Line 15,
Columns 2-4

Change of formula:

These columns are now protected and pull the
information directly from Work Sheet D.

To reflect CMS’s changes to Work
Sheet D.

83.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 16

Change to read:

“Capitation……………………..”

To reflect CMS’s changes to Work
Sheet D.

Page 17 of 26

Issue
#
84.

Page #

Section

Action to be
performed
Change of formula:

Changes to the Application

Reason for the Change

Work
Sheet K

Line 16,
Columns 2-4

These columns are now protected and pull the
information directly from Work Sheet D.

To reflect CMS’s changes to Work
Sheet D.

85.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 17

Change to read:

“Other………………………”

To reflect CMS’s changes to Work
Sheet D.

86.

Work
Sheet K

Line 17,
Columns 2-4

Change of formula:

These columns are now protected and pull the
information directly from Work Sheet D.

To reflect CMS’s changes to Work
Sheet D.

87.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 18

Change to read:

“ESRD Facilities………………………”

To reflect the changes made on
Work Sheet K, this cost center
changed numbering.

88.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 20

Change to read:

“Durable Medical Equipment…………………..”

To reflect the changes made on
Work Sheet K, this cost center
changed numbering.

Page 18 of 26

Issue
#
89.

Page #

Section

Action to be
performed
Change to read:

Changes to the Application

Reason for the Change

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 21

“Ambulance…………………………….”

To reflect the changes made on
Work Sheet K, this cost center
changed numbering.

90.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 22

Change to read:

“Emergency-Urgently Needed Svcs……..”

To reflect the changes made on
Work Sheet K, this cost center
changed numbering.

91.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 23

Change to read:

“Professional Component – Mental Health……”

To reflect the changes made on
Work Sheet K, this cost center
changed numbering.

92.

Work
Sheet K

Column
Titled “Cost
Centers”,
Line 24

Change to read:

“Mental Health Svcs – Non-Prof Component…”

To reflect the changes made on
Work Sheet K, this cost center
changed numbering.

93.

Work
Sheet L

Column
Change line to read:
Titled
“Description”
, Line 18

“Pt B DED pd by MAC/Carrier/Inter (Wkst E, Col 6,
Ln 16)…”

This is a CMS correction to the
Cost Report. This line incorrectly
states column 9, and there is no
column 9 on wkst E. It should
state Column 6

Page 19 of 26

Issue
#
94.

Page #

Section

Changes to the Application

Reason for the Change

Line 21

Action to be
performed
Change Line to read:

Work
Sheet L

“Pro Component of Mental Health Svcs (W/S K, Line
23)….”

To correct label the description
from “Line 19” to “Line 23”

95.

Work
Sheet L

Line 22

Change Line to read:

Line 21 times 25%...

To correct label description from
“37.5%” to “25%”

96.

Work
Sheet L

Line 22,
Column 2

Formula:

This number is determined by multiplying the amount
in Column 2, Line 21 by 25%.

To correct formula by changing
37.5% to 25%

97.

Work
Sheet L

Line 24

Add a blank line:

Insert a blank line, exactly like line 20 on the same
worksheet. This line is blocked out grey in columns 16.

This line provides a blank space.

98.

Work
Sheet L

All Columns

Add all new lines:

There are additional lines that need to be inserted. The
new lines will be numbered from 24-26.

As a result to the previous changes
to the cost report, these lines need
to be entered.

99.

Work
Sheet L

Column
Add a new line:
Titled
“Description”

“Part B Costs Not Subject to
Coinsurance……………”

This is CMS’ title for the new cost
center.

Page 20 of 26

Issue
#

Page #

Section

Action to be
performed

Changes to the Application

Reason for the Change

Add block of grey:

These columns on this line should be grayed out
exactly like line 18 on the same Work Sheet L.

These columns are not in use for
this cost center on this worksheet.

Add a number cell:

A space to pull the dollar value associated with this
cost center from Worksheet E, Column 6, Line 19.

Add a number cell:

A space to total out column 2.

This Cost Center is reimbursed at
100%, but needs to be broken up
into a Per Member Per Month
amount. Worksheet L
accomplishes this task.
CMS will need a total to break
down into the Per Member Per
Month amount. This line computes
this amount.
This labels the calculation so that
the Per Member Per Month
amount can be determined.

100.

Work
Sheet L

101.

Work
Sheet L

, Line 25
Line 25,
Columns
1,4,5, 6.
Line 25,
Column 2

102.

Work
Sheet L

Line 25,
Column 3

103.

Work
Sheet L

“Cost PMPM (Line 25/ Line 1)…………………….”

104.

Work
Sheet L

Column
Add a new line:
Titled
“Description”
, Line 26
Line 26,
Add a block of grey:
Columns
1,4,5.

These columns on this line should be grayed out
exactly like line 18 on the same Work Sheet.

These columns are not in use for
this cost center on this worksheet.

105.

Work
Sheet L

Line 26,
Column 2

Formula:

This number divides the amount in Column 2, Line 25
by Column 2, Line 1.

106.

Work
Sheet L

Line 26,
Column 3

Add a number cell:

A space to total out column 2 in PMPM amounts.

This Cost Center is reimbursed at
100%, but needs to be broken up
into a Per Member Per Month
amount. Worksheet L
accomplishes this task.
CMS will need a total to break
down into the Per Member Per
Month amount. This line computes
the number.

Page 21 of 26

Issue Page #
#
107. Work
Sheet L

Section
Column 6,
Line 26

Work
Sheet M
109. Work
Sheet N

108.

Column 3,
Line 16a
Column
Titled
“Premium
Determinatio
ns Covered
by this Part”,
Line 8c
110. Work Column 3,
Sheet N Line 8a

Action to be
performed
Add:

Changes to the Application

Reason for the Change

“M

This is the Work Sheet and Line
that the number in Column 3, Line
26 transfers to from this page.

Linked to:

This space should be protected and pull information
from Work Sheet L, Column 3, Line 26
“CO pd by MAC/Carrier/Inter (Worksheet G, Col 2,
Line 23&24/WS D, Pt E, Col 2, Ln 1)

This will pull the correct amount
from a previous Work Sheet
This is a CMS correction to the
Cost Report.

Linked to:

This space should be protected and pull information
from Worksheet M, Column 4, Sum of lines 8-11

This removed the potential for data
entry error by following the
instructions and calculating this
cell correctly by linking it to the
referenced cells.

This removed the potential for data
entry error by following the
instructions and calculating this
cell correctly by linking it to the
referenced cells.
This removed the potential for data
entry error by following the
instructions and calculating this
cell correctly by linking it to the
referenced cells.

Change line to read:

16a”

111.

Work
Sheet N

Column 3,
Line 8b

Linked to:

This space should be protected and pull information
from Worksheet M, Column 3, Line 13

112.

Work
Sheet N

Column 3,
Line 8c

Linked to:

This space should be protected and pull information
from Worksheet G, Col 2, Line 23&24/WS D, Pt E,
Col 2, Ln 1

Page 22 of 26

Issue Page #
#
113. Work

Section
Line 9a

Action to be
performed
Change Line Number

Changes to the Application

Reason for the Change

Changes line number from 9 to 9a

This is a CMS change to the Cost
Report that reflects a new line
number.

Change line to read:

“Involuntary under/ (over) collection for the prior
period (Worksheet N, Line 11/12b, respectively)
**Note** Prior period = Current period – 2 years”.

This is a CMS change to the Cost
Report that reflects the proper
number pulled from the prior
period Worksheet N.

Add line

Line will read “Prior Period Member Months”

This is a CMS change to the Cost
Report to correctly reflect prior
period collections at the current
period’s membership.

Linked to:

This space should be linked to the prior period,
Worksheet N, Line 0.

This is a CMS change to the Cost
Report to correctly reflect prior
period collections at the current
period’s membership.

Add line

Line will read “Gross under/ (over) collections from
prior period”

This is a CMS change to the Cost
Report to correctly reflect prior
period collections at the current
period’s membership.

Sheet N

114.

Work
Sheet N

Column
Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 9a
Work
115.
Column
Sheet N Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 9b
116. Work Column
sheet N Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 9b
117. Work Column
sheet N Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 9c

Page 23 of 26

Issue Page #
#
118. Work

Section

Column
Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 9c
119. Work Column
sheet N Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 9d
120. Work Column
sheet N Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 9d
Work
121.
Column
Sheet N Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 10

Action to be
performed
Formula:

Changes to the Application

Reason for the Change

This line will calculate as the product of Line 9a *
Line 9b.

This is a CMS change to the Cost
Report to correctly reflect prior
period collections at the current
period’s membership.

Add line:

Line will read “Adjusted under/ (over) collection from
the prior period”

This is a CMS change to the Cost
Report to correctly reflect prior
period collections at the current
period’s membership.

Formula:

This line will calculate as Line 9c divided by Line 0.

This is a CMS change to the Cost
Report to correctly reflect prior
period collections at the current
period’s membership.

Change line to read:

“Total Amount Allowed to be charged (line 8d plus
line 9d)”

This is a CMS change to the Cost
Report that reflects the cumulative
actual amount allowed to be
charged for the current period.

sheet N

Page 24 of 26

Issue Page #
#
122. Work

Section

Column
Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 10
123. Work Column
Sheet N Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 11
124. Work Column
Sheet N Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 11
Work
125.
Column
sheet N Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 12
126. Work Column
sheet N Titled
“Premium
Determinatio
n Covered by

Action to be
performed
Formula

Changes to the Application

Reason for the Change

This line will calculate as Line 8d plus line 9d

This is a CMS change to the Cost
Report that reflects the cumulative
actual amount allowed to be
charged for the current period.

Change line to read:

“Actual under (over) collection for the period (Line 10
minus Line 7). Stop here is (over)collection.”

This is a CMS change to the Cost
Report to calculate the actual
under or over collection for the
period.

Formula:

Change this line to calculate as Line 10 minus Line 7

This is a CMS change to the Cost
Report to calculate the actual
under or over collection for the
period.

Change line to read:

“Budgeted Voluntary under collection for the period
(Worksheet B, Line 8)”

This is a CMS change to the Cost
Report to reflect budgeted under
collections estimated on the
Budget Report.

Linked to:

This line will link to the current period’s Worksheet B,
Line 8.

This is a CMS change to the Cost
Report to reflect budgeted under
collections estimated on the
Budget Report.

Sheet N

Page 25 of 26

Issue
#

Page #

127.

Work
sheet N

128.

Work
sheet N

129.

Work
sheet N

130.

Work
sheet N

Section
this Part”,
Line 12
Column
Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 12a
Column
Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 12a
Column
Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 12b
Column
Titled
“Premium
Determinatio
n Covered by
this Part”,
Line 12b

Action to be
performed

Changes to the Application

Reason for the Change

Add line:

Line will read “Actual Voluntary Under collection –
no recoupment”

This is a CMS change to the cost
report to limit any budgeted under
collections from the budget report
to actual under collections.

Formula:

Line will calculate as either the voluntary under
collection from the budget report, or the actual under
collection, whichever is less.

This is a CMS change to the cost
report to limit any budgeted under
collections from the budget report
to actual under collections.

Add line

Line will read “Involuntary under collection – may
recoup during subsequent period”

This is a CMS change to the cost
report to limit any budgeted under
collections from the budget report
to actual under collections and
allow recoupment of involuntary
under collections in future periods.

Formula:

Line will calculate as the different between the actual
under collection and the voluntary under collection
calculated on Worksheet B, Line 8 of the budget
report.

This is a CMS change to the cost
report to limit any budgeted under
collections from the budget report
to actual under collections and
allow recoupment of involuntary
under collections in future periods.

Page 26 of 26